




fri^htF i<no 



COPYRIGHT DEPOSIT. 










;", .-,' ', " \f. 






■C'-f 



THE DISEASES 



OF 



INFANCY AND CHILDHOOD. 



DESIGNED FOR THE USE OF 



STUDENTS AND PRACTITIONERS OF MEDICINE. 



BY 

HENRY KOPLIK, M.D., 

ATTENDING PHYSICIAN TO THE MOUNT SINAI HOSPITAL; CONSULTING PHYSICIAN TO THE HOSPITAL 

FOR DEFORMITIES, FORMERLY ATTENDING PHYSICIAN TO THE GOOD SAMARITAN DISPENSARY, 

THE ST. JOHN'S GUILD HOSPITALS, NEW YORK ; EX-PRESIDENT OF THE AMERICAN 

PEDIATRIC SOCIETY | MEMBER OF THE ASSOCIATION OF AMERICAN PHYSICIANS, 

AND OF THE NEW YORK ACADEMY OF MEDICINE. 



THIRD EDITION, REVISED AND ENLARGED. 



ILLUSTRATED WITH 204 ENGRAVINGS AND 39 PLATES IN 
COLOR AND MONOCHROME 




LEA & FEBIGER, 

NEW YORK AND PHILADELPHIA. 



THE DISEASES 



OF 



INFANCY AND CHILDHOOD. 



DESIGNED FOR THE USE OF 



STUDENTS AND PRACTITIONERS OF MEDICINE. 



BY 



HENRY KOPLIK, M.D., 



ATTENDING PHYSICIAN TO THE MOUNT SINAI HOSPITAL J CONSULTING PHYSICIAN TO THE HOSPITAL 

FOR DEFORMITIES, FORMERLY ATTENDING PHYSICIAN TO THE GOOD SAMARITAN DISPENSARY, 

THE ST. JOHN'S GUILD HOSPITALS, NEW YORK ; EX-PRESIDENT OF THE AMERICAN 

PEDIATRIC SOCIETY J MEMBER OF THE ASSOCIATION OF AMERICAN PHYSICIANS, 

AND OF THE NEW YORK ACADEMY OF MEDICINE. 



THIRD EDITION, REVISED AND ENLARGED. 



LLUSTRATED WITH 204 ENGRAVINGS AND 39 PLATES IN 
COLOR AND MONOCHROME 




LEA & FEBIGER, 

NEW YORK AND PHILADELPHIA. 



1 



Entered according to Act of Congress, in the year 1910, by 

LEA & FEBIGER, 

In the Office of the Librarian of Congress. All rights reserved 



©CI.A261- 



THIS WORK 
IS INSCRIBED TO MY PRECEPTORS, 

FRANCIS DELAFIELD, M.D., LL.D., 

EMERITUS PROFESSOR OP THE PRACTICE OF MEDICINE IN THE COLLEGE OF 
PHYSICIANS AND SURGEONS, COLUMBIA UNIVERSITY, NEW YORK, 

AND 

MATHEW D. MANN, M.D., 

PROFESSOR OF OBSTETRICS AND GYNAECOLOGY IN THE UNIVERSITY 
OF BUFFALO, NEW YORK 



PREFACE TO THE THIRD EDITION 



The preparation of a third edition of this work has brought the 
opportunity to revise it as well as to introduce new matter. The 
advances in our knowledge of the special pathology, diagnosis and 
treatment of the most important diseases of infancy and childhood 
during the past three years have been such as to add materially to 
our understanding of many obscure problems in Pediatrics. I have 
therefore in the light of these advances and my own accumulating 
experience added to or recast many chapters of this work. In the 
technic of treatment and diagnosis of the infectious diseases the 
reader will find much that is new and yet well tried in practice. 
Infant feeding, which has advanced as to our understanding of cer- 
tain disturbances of nutrition, has been carefully revised ; the diseases 
of the stomach, and those of the nervous system, such as cerebral 
palsies, encephalitis, poliomyelitis, tetany, amaurotic idiocy, have 
been recast. The chapters on cystitis and pyelitis have also been 
brought up to date ; and chapters have been added on idiocy, dwarf- 
ism, neurotic conditions which will be found to be of value to the 
practitioner. The illustrations have been enriched by carefully exe- 
cuted drawings of my own cases for the most part and those of 
patients in institutions with which I am connected. I wish to thank 
my colleagues, Drs. E. Lee Meierhof, Curtis C. Eves, and G. S. 
Dixon, for their kind cooperation in preparing the illustrations for 
the chapters on adenoids and the examination of the ear ; and also 
Dr. Henry Frauenthal, for illustrations of cases of poliomyelitis and 
cerebral palsies. To my publishers thanks are due for their uniform 
courtesv and encouragement. 

The Author. 
30 East Sixty-second Street, 
New York, 1910. 



CONTENTS, 



SECTION I. 

INFANCY AND CHILDHOOD. 

PAGE. 

Definition — Infancy — Childhood — Newborn. Morbidity in newborn — In child- 
hood. Mortality, in large cities, in various diseases — Statistics. Sudden 
death among infants and children — Premature birth. Circulatory disturb- 
ances as causal factors — Diseases of the respiratory tract, affections of 
the central nervous system, other causes. Surgical causes, lymphatism. 
The normal infant and child, body weight — Length of body, head — Kespir- 
atory functions, shape of chest, chest circumference, normal number of 
respirations, chemism of respiration. Circulation and pulse — Table of 
average height, weight, head circumference and chest measurements of 
American children. Pulse rapidity, rhythm. Body temperature — Urine — 
Physical characters, urea, albumin, indican, acetone, diacetic acid, uro- 
bilin, dextrose, casts, uric acid infarctions. Mental and physical develop- 
ment of the infant — sight, hearing, taste, feelings of pleasure — power to 
hold the head upright — Standing, crawling, walking, laughing, kissing — 
Memory, speech. Methods of examination — History taking. Maternal 
history, parental history, onset of illness. Status preesens, the skin, head, 
face, respiration, heart, facial palsy, nuclear palsy, Basedow's disease, 
hydrocephalus, rachitis, exhausting diseases, congenital syphilis, palpebral 
fissure, sight, photophobia, nystagmus. The chest — position of the patient. 
Instruments used, methods, inspection, palpation, percussion, auscultation. 
The abdomen, inspection, peritonitis, free fluid, tumors, palpation, ascites, 
tympanites, pain. Eectal exploration, the joints, motility, joint crepitus. 
The spine anatomy, method of examination. Muscular apparatus and 
nervous system, reflexes, patellar reflex, Babinski 's reflex, Kernig 's symp- 
tom. Gait, walk, ataxia, cerebellar gait, spastic walk, limping gait, infan- 
tile paralysis. Management and hygiene of the normal infant. Taking 
the infant from the mother at birth. Tying of the cord, care of the cord, 
bathing — the first bath, daily bath, hardening. Eyes, care of. Method 
of taking temperature. Diapers, care of the genitals. Play, fondling. 
Sleep — Bed — Nursery — Open air exercise. Clothing, body binder. Skin. 
Mouth — Administration of drugs and other methods of therapy. Medic- 
inal treatment, antipyretics, dosage, hypodermic medication, hydrotherapy, 
sponge bath, cold chest compress, cold pack, full bath, hypodermoclysis, 
syringing the nose, instruments and methods. Vapor spray, calomel inha- 
lations, stomach washing, indications, method, gavage. Rectal enemata. 
irrigation, enteroclysis. Lumbar puncture, normal cerebrospinal fluid, 
abnormal conditions, specific gravity, gross appearances, tuberculous men- 
ingitis, suppurative meningitis, epidemic meningitis, chronic hydroceph- 
alus, brain tumors, sediment, cytology, pressure, operation of lumbar 
puncture, indications, place, method, dangers o\' lumbar puncture. The 
introduction o\' sera and drags into the spinal canal 17 BO 



vi li COX TEX IS. 

SECTION II. 

NUTRITION AXD INFANT FEEDING. 

PAGE. 

Principles underlying the sses of nutrition, -water, mineral salts, proteids. 

fats, carbohydrates. Metabolism in the nursing infant, mineral salts. 
excreta, water, carbonic acid gas. Metabolism in the bottle-fed infant. 
Caloric needs in breast- and bottle-fed infants. The food of the infant. 
human breast milk, colostrum, physical properties, composition, milk 
appearance in breast, composition, proteids. fats, mineral salts, reactions, 
specific gravity, bacteria in breast milk, enzymes and alexins of breast 
milk, amount of breast milk consumed in twenty-four hours, changes in 
the composition of breast milk, influence of foods on breast milk, drugs 
and foreign substances in the milk, bacteria in the infectious diseases in 
breast milk, toxins, antitoxins and agglutinins. Menstruation, pregnancy. 
Methods of analysis of breast milk, specific gravity. Conrad's method, 
fats. Lewi's method, the proteids. Cows' milk, composition, fat. protei ".-. 
bacteria in cows' milk, infected cows ' milk as a cause of epidemics, typhoid 
fever, dysentery, diphtheria, scarlet fever, cholera, tuberculosis. Milk 
acidity, pasteurization, sterilization, disadvantages, assimilation of raw. 
pasteurized and sterilized milk. Attitude of the physician in regard to 
pasteurization and sterilization. Eaw milk in infant feeding, frozen milk, 
nursing bottles. Food preparations, peptonized milk, condensed milk, 
barley water, oatmeal gruel, arrowroot gruel, beef juice, peptone prepa- 
rations, butter milk, beef extracts, kumyss. beef broth, acorn cocoa. 
Artificial infant foods — composition, table of. classification. Maternal 
nursing, contra-indications to maternal nursing. Selection of a wet- 
nurse. Quantity of milk in breasts, beginning of nursing. Care of 
breasts, fissured nipples, caking of breasts, nursing the infant, signs of 
efficient nursing, inefiicient nursing. Mixed feeding — method of establish- 
ing. Artificial feeding of infants, the food. Biedert 's mixture. Meig 's 
mixture. Eotch method, percentage feeding, principles, proteids. fats. 
sugar, water, salts, number of feedings necessary and quantity of each 
nursing, tables, household modification of milk for infant feeding, method 
of. Top milks — Twelve per cent., seven per cent, fat milk. Top milk 
at home, home preparation of modified milk, method of calculating per- 
centages, problems, construction of formula?. Too high fats and remedies, 
diluents, reaction. When is a bottle-fed infant thriving? Table of feed- 
ings — Spitting, colic, fat diarrhoea, greenish movements, disturbances on 
border bine of normal and abnormal — Vomiting, low proteids. low fats, 
assimilation without increase of weight. When to peptonize food. Whey 
method of milk modification. The use of infant foods — Barley gruels. 
utilization — Dextrinized gruels. Food after the sixth month. Feeding 
from the ninth to the twelfth month — weaning. Feeding from the twelfth 
to the eighteenth month. Feeding from the eighteenth month to the end 
of the second year. Feeding from the third to the sixth year and after. 

ling of sick infants and children Sl-164 



CONTENTS. X 

SECTION III. 

DISEASES OF THE NEWBOBN. 

PAGE. 

Physiology of the newborn — Kespiration— Circulation — Pulse — Blood — Diges- 
tive functions — Body temperature — Skin — Breasts — Urine — Rectal excreta 
— Nervous system — Metabolism — Excretion and waste. Mortality and 
sudden death in the newborn. Congenital anomalies — Of the scrotum — 
Testes — Hydrocele congenita or adnata. The congenitally weak (prema- 
ture infants) — Management of congenitally weak infants: incubators — - 
Bath and clothing of the congenitally weak — Ultimate fate of the incu- 
bator infant — Feeding of the congenitally weak and rjremature infants. 
Asphyxia of the newborn infant. Asphyxia subsequent to birth. Atelec- 
tasis of the lungs. Septic infection of the newborn infant. Diseases of 
the umbilicus — Omphalitis — Umbilical fungus — Blennorrhoea of the um- 
bilicus — Phlegmon of the umbilicus — Ulcer of the umbilicus — Gangrene 
of the umbilicus — Erysipelas of the umbilicus — Infection of the umbilical 
vessels — Phlebitis umbilicalis — Hemorrhage from the umbilicus — Idio- 
pathic hemorrhage from the umbilicus — Umbilical hernia?. Peritonitis of 
the newborn. Tetanus of the newborn infant. Icterus in the newborn 
infant. Icterus gravis of the newborn. The occurrence of hemorrhage 
in the newborn. Melsena neonatorum. Acute fatty degeneration of the 
newborn. Winckel 7 s disease. Sclerema. Ophthalmia neonatorum. Caking 
of the breasts. Mastitis. Injuries inflicted during birth. Paralyses. 
Haematoma of the sternomastoid. Cephalhematoma 165-236 



SECTION IV. 

DISEASES DUE TO DISTUEBANCES OF NUTRITION. 

Rachitis — Chondrodystrophia fcetalis — Osteogenesis imperfecta — Infantile scor- 
butus. Marasmus or infantile atrophy 237-264 

SECTION V. 

THE SPECIFIC INFECTIOUS DISEASES. 

The Exanthemata — Scarlet fever. Rotheln. Measles. Varicella. Vaccina- 
tion — Other specific infectious diseases. Typhoid fever. Malarial fever. 
Influenza. Glandular fever. Meningitis — Cerebrospinal meningitis — Acute 
lepto-meningitis. Posterior basic meningitis. Meningitis serosa. Mumps. 
Pertussis convulsiva. Diphtheria — Diphtheroid. Scrofula. Tuberculosis: 
foetal tuberculosis — Pulmonary tuberculosis — Tuberculosis of the peri- 
toneum; other forms of tuberculosis (larynx; pleura; pericardium) — 
Abdominal tuberculosis — Tuberculous meningitis — Tuberculosis ox the 
brain. Syphilis: Acquired syphilis— Late hereditary syphilis — Congenital 
or hereditary syphilis. Acute articular rheumatism. Rheumatoid arthritis 
(Still's disease). Other forms of so-called rheumatism, gonorrhoea! form 
— Poliosis, tonsillitis with joint pains and endocarditis. Erythema nodo- 
sum, subcutaneous rheumatic nodules. Muscular rheumatism 265 167 



x CONTEXTS. 

SECTION VI. 

DISEASES OF THE MOUTH. 

PAGE. 

Physiological facts — Physiology of the nursing act. Landmarks of the normal 
mouth. Bacteria of the mouth. Normal dentition — Abnormal dentition. 
Pathology of dentition, ulcerations at the angles of the mouth. Bednar's 
aphtha?, sprue. Aphthous stomatitis, toxic stomatitis, ulcerative stoma- 
titis. Gonorrheal infections of the mouth. Pseudodiphtheritic stomatitis. 
Xoma. Diseases of the tongue. Anomalies of size. Kingworni — Des- 
quamation, tongue swallowing — Tongue tie — Malformations of the uvula. 
Diseases of the oesophagus. Congenital anomalies — Branchial fistula? 
diverticula? — Stricture, absence. Oesophagitis — Caustic oesophagitis. Peri- 
oesophageal abscess 468^92 

SECTION VII. 

DISEASES OF THE STOMACH AXD IXTESTIXES. 

Classification. Anatomy of stomach, capacity — Marking out the stomach 
by percussion. Function and motility. Acids of stomach — Stomach 
digestion — Intestinal digestion. Stools, characteristics. Acute gastric 
dyspepsia. Habitual vomiting. Cyclic vomiting. Other forms of vom- 
iting. Colic — Tympanites. Dilatation of the stomach. Ulcer of the 
stomach. Spasm and congenital stenosis of the pylorus. Acute gastro- 
enteric infection. Cholera infantum. Acute and subacute enterocolitis. 
Dysentery and paradysentery. Amoebic dysentery. Constipation in infants 
and children. Congenital dilatation of the colon. Acute intestinal obstruc- 
tion. Appendicitis. The rectum — Prolapsus ani. Fissure of the anus — 
Proctitis — Polypus of the rectum. Intestinal parasites — Diseases of the 
liver. Anatomical considerations. Tumors and conditions simulating en- 
largement. Jaundice — Congenital stenosis of the bile ducts. Cirrhosis 
of the liver — Fatty degeneration of the liver. Syphilis of the liver. 
Abscess of the liver. Acute yellow atrophy. Tumors of the liver. Para- 
sites of the liver. Biliary calculi. Diseases of the peritoneum. Ascites. 
Acute peritonitis. Gonococcal peritonitis. Pneumococeus peritonitis. 
Simple chronic peritonitis 493-573 

SECTIOX VIII. 

DISEASES OF THE KE SPUR ATOPY SYSTEM. 

Diseases of the nose and nasopharynx — Acute nasal catarrh — Chronic nasal 
catarrh — Diphtheritic rhinitis — Foreign bodies in the nose — Epistaxis — 
Adenoid growths — Acute retropharyngeal abscess. Diseases of the tonsils 
— Acute follicular amygdalitis — Herpes of the tonsils — Ulceromembra- 
nous tonsillitis. Diseases of the larynx — Acute catarrhal laryngitis — 
(Edema glottidis — Syphilis of the larynx — Tuberculosis of the larynx — 
Growths in the larynx — Foreign bodies in the larynx. Diseases of the 
bronchi — Acute simple bronchitis — Fibrinous or plastic bronchitis — Em- 
physema and chronic bronchitis — Bronchiectasis. Diseases of the lungs 
— General considerations, movements of the chest, normal limits of the 



CONTENTS. xi 

PAGE. 

lung; resiliency of the chest wall, percussion, auscultation, types of 
- breathing, forms of dyspnoea — Pneumonia — Lobar pneumonia — Broncho- 
pneumonia — Persistent bronchopneumonia. Diseases of the pleura — 
Pleurisy — Dry pleurisy — Pleurisy with effusion and empyema — Perforat- 
ing empyema — Hemorrhagic pleurisy and empyema — Subphrenic abscess 

574-673 

SECTION IX. 

DISEASES OP THE CIRCULATORY SYSTEM. 
Pericarditis — Adherent pericardium. Diseases of the heart — Heart, position, 
size, apex beat, examination of the heart — Congenital heart disease — Ste- 
nosis of the pulmonary artery, conus or ostium — Open ductus arteriosus 
— Congenital septum defects — Maladie de Roger — Acute endocarditis — 
— Septic endocarditis — Chronic valvular disease of the heart — Cardiac 
murmurs — Accidental cardiac murmurs — Myocarditis — Hypertrophy and 
dilatation of the heart 674-710 



SECTION X. 

GENERAL CONSTITUTIONAL DISEASES. 
Diabetes mellitus — Diabetes insipidus 711-714 



SECTION XI. 

DISEASES OF THE LYMPH-NODES, DUCTLESS GLANDS, 
AND THE BLOOD. 

Diseases of the lymph-nodes — Acute adenitis — Chronic lymphadenitis. Dis- 
eases of the thyroid gland — Enlargements of the thyroid — Cretinism, 
endemic and sporadic. Mongolian Idiocy — Infantilism — Dwarfism — Nan- 
ism. Diseases of the thymus: landmarks, weight — Percussion — X-ray — 
Hypertrophy of the thymus, status lymphaticus, thymus death. Diseases 
of the spleen: anatomical— Examination of splenic and kidney tumors. 
Diseases of the blood — Leading characteristics in infancy and childhood, 
the red blood-cells, the white blood-cells, the haemoglobin, the specific 
gravity — Anaemia — Simple anaemia — Chlorosis — Pseudoleukemia anaemia 
of von Jaksch — Leukaemia — Acute leukaemia — Chronic leukaemia — Hodg- 
kin 's disease — Hemorrhagic diathesis — Simple purpura — Haemophilia — 
Purpura hemorrhagica — Purpura rheumatica — Henoch 's purpura — Per- 
nicious anaemia. Diseases of the suprarenal bodies — Addison's disease 

715 754 

SECTION XII. 

DISEASES OF THE BONES, 

General considerations, tuberculosis, craniotabes, syphilis —Acute infectious 
osteomyelitis 7 - 



Xll CONTENTS. 

SECTION XIII. 

DISEASES OE THE EAE. 

PAGE. 

Otitis in infancy and childhood. Otitis media catarrhalis — Method of exami- 
nation of the ear in infants and children. Mastoid disease — General 
facts — Anatomy — Etiology — Symptoms — Diagnosis — Treatment 759-769 

SECTION XIV. 

DISEASES OF THE KIDXEYS AXD UROGENITAL TRACT. 

General anatomy — Floating kidney — Cyclic albuminuria — OZdema and hydre- 
mia without kidney lesion — Dysuria — Cellular atresia labia — Hematuria 
— Hemoglobinuria — Eenal calculi — Acute nephritis — Chronic diffuse ne- 
phritis — Growths of the kidney — Cysts, hydronephrosis, sarcoma, carci- 
noma — Tuberculosis, peri- and para-nephritis, enuresis, nocturna and 
diurna — Vulvovaginitis — Urethritis in male children — Cystitis — Pyelitis — 
Pyelonephritis — Bacilluria 770-796 

SECTION XV. 

DISEASES OF THE NERVOUS SYSTEM. 

Convulsions in infancy and childhood — Eclampsia infantum — Hysteria — Bad 
habits — Pica — Puddling — Thumb sucking — Head hanging — Masturbation 
— Tetany — Catalepsy — Myotonia — Congenital stridor — Laryngismus strid- 
ulus — Epilepsy — Pavor nocturnns — Chorea — Forms of tic — Ehythmic 
movements of the head, with nystagmus — Hydrocephalus — Amaurotic 
idiocy — Tumors of the brain — Infantile cerebral palsy — Hemiplegic infan- 
tile cerebral palsy — Facial palsy — Multiple neuritis — Erb "s palsy — Hered- 
itary ataxia — Acute encephalitis — Acute poliomyelitis — Juvenile form of 
progressive muscular atrophy — Landouzy type of facio-scapulo-humeral 
form of muscular atrophy — Pseudohypertrophic muscular paralysis — Idiocy 
— Deformities of skull and spinal canal — Spina bifida 797-883 

SECTION XVI. 

DISEASES OF THE SKIX. 

General facts — Eczema — Erythema multiforme — Furunculosis — Sudamina 
— Dermatitis exfoliativa — Congenital ichthyosis — Pemphigus neonatorum 

884-895 



DISEASES OF INFANCY AJLOHILMOOD. 



SECTION I. 

INFANCY AND CHILDHOOD. 

DEFINITION OF INFANCY AND CHILDHOOD. 

Infancy, or the nursing age, is the period of life during which the 
child is at the breast. It extends from birth to the twelfth month. 

Childhood is the succeeding period, extending to puberty. It is 
customary to divide childhood into two periods — the first extending 
from the end of the first to the sixth or seventh year, or the beginning 
of the second dentition ; the second, from this to puberty. 

The period of the newborn extends to the third month. 

MORBIDITY. 

The Newborn Infant. — The diseases of the newborn are, for the 
most part, septic in nature, and attack the infant within a short time 
after birth. 

Certain conditions favor the occurrence of the diseases common at 
this time of life. The skin, not fully formed, is in process of 
desquamation, and bacteria easily gain access to the circulation. The 
umbilicus is an open wound, receptive of infection. The mucous 
membranes of the intestine, mouth, eye, and ear are avenues for the 
entrance of bacteria. There is a tendency for minor infections to 
become general at this period. The artificially fed infant is, more- 
over, exposed to the dangers which necessarily accompany the intro- 
duction into the body of a foreign food with its attendant uncleanli- 
ness, and is also deprived of the protective bodies (alexins) contained 
in the mother's milk. With new surroundings, in a new atmosphere, 
with new appliances for maintaining the body-heat (such as clothes), 
and with careless handling, the newborn infant is peculiarly exposed 
to disease. 

Childhood. — The study of the statistics of any large pediatric 
clinic will at once show that up to the tenth year o\' life those diseases 
which affect the respiratory apparatus form nearly two-fifths of the 
cases. Next in order of frequency are the diseases o\ the digestive 

2 17 



18 1XFAXCT AXD CHILDHOOD. 

tract ; and, lastly, the acute infectious diseases, such as the fevers and 
exanthemata. Of 53,040 cases met with during five years in an 
ambulatory clinic, there were 20,207 cases of diseases of the respira- 
tory organs, 17,058 of the gastro-enteric tract, and 24:09 of the acute 
infectious diseases. 

If the morbidity is analyzed still further, it is seen that in the 
nursing period intestinal disturbances are the most frequent. The 
numerous flora of bacteria and their toxins in the intestine of the 
infant rather predispose to infections from that source. These bac- 
teria may invade the mucous membrane of the intestine, and in 
certain disturbances of the functions of the gat obtain access to the 
circulation. The respiratory diseases become more frequent in the 
second year, and reach their maximum frequency between the second 
and third years. Constitutional diseases, such as rachitis, appear in 
the second half-year of life, and reach their greatest frequency during 
the period from the tenth to the fifteenth month. On the other hand, 
the acute infectious diseases, such as the exanthemata, are more 
common from the fifth to the eighth year. Scarlet fever, with its 
kidney complications, is most frequent at the fourth year (Escherich), 
diminishing at the ninth year. 

The period extending from the second to the fourth year is also 
notable for the frequency of the so-called " filth infections " of Feer. 
Children infect themselves with dirt and dust at play, at meals or 
in their intercourse with one another. For this reason, diphtheria as 
well as pertussis and tuberculosis (Escherich) attain their maximum 
frequency at this period. 

MORTALITY. 

In large cities the mortality of infants is naturally greatest among 
the poor, due to unhygienic conditions. With the well-to-do artificial 
feeding is resorted to for social reasons, but among the poor a mother 
who is forced to make her livelihood must deny the breast to her 
child. The greatest mortality in all countries occurs in artificially 
fed infants. In England two-fifths of the whole number of deaths 
occur before the tenth year and one-fourth before the end of the 
first year. The same is true of America. The modes of life among 
the poor and the total lack of isolation in contagious disease tend to 
foster this great mortality. In a recent brochure Phelps shows that 
for the past twenty-five years, the mortality among infants under one 
year of age. in spite of the great advances in prophylaxis and infant- 
feeding, has remained much the same in all countries the world over. 
He places the rate at 154 per thousand births, whereas Eross found 
it to be 186 per thousand. In answer to this Holt has recently shown 
that the greatest mortality among infants under one vear of ao;e occurs 



SUDDEN DEATH AMONG INFANTS AND CHILDREN. 



19 



in the summer months from gastro-intestinal disorders and that 
during the past hundred years, in the State of New York at least, 
there has been a gradual improvement in the death-rate, though the 
actual number of deaths is certainly greater because of the increase 
in population. The following tables show the improvement in death- 
rate during the past four years in the State of New York. 



1904. 
1905. 
1906. 
1907. 
1908. 



Total 
mortality. 



142,217 
137,435 
141,099 
147,130 
138,912 



Mortality 

under 
5 years. 



14,177 
12,218 
12,176 
12,157 
11,380 



Under 
1 year*. 



24,909 
25,827 
27,114 
28,011 
26,561 



Total 
births. 



165,014 
172,259 
183,012 
196,020 
203,159 



Annual 
number 
of deaths 
under 
1 year 
to 1,000 
living 
births. 



ercentage 
under 


Percentage 
of deaths 


1 year 
to total 
deaths. 


5 years 
to total 
deaths. 



151.0 
150.0 
148.1 
142.9 
130.7 



17.5 
18.8 
19.2 
19.0 
19.1 



27.5 
27.7 
27.9 
27.3 
27.3 



This encouraging result must be ascribed to the improvement of the 
milk-supplies in large cities, the education of the poor, the introduc- 
tion of serum-therapy in the infectious diseases, and a livelier interest 
in the prophylaxis of disease with consequent absence of decimating 
epidemics. 



SUDDEN DEATH AMONG INFANTS AND CHILDREN. 

Sudden death, that is, death which supervenes unexpectedly either 
in apparent health or in the course of disease, is very frequent in 
infancy and childhood. It is not quite as frequent at this age as in 
adult life. It is well, however, to recognize that this form is of daily 
occurrence, lest suspicion as to the cause of death, in any case, may 
unjustly attach to the physician or those who surround the child. 
Sudden death may be traced in most cases to anatomical or patho- 
logical conditions either in the circulatory apparatus, the respiratory 
apparatus, or the nervous system. Sometimes the cause must remain 
undetermined. Finally, it may supervene during or after surgical 
operations, either in the stage of anaesthesia or after the operation 
has been completed and the patient is apparently doing well. 

Premature Birth. — In the newborn, if premature, death may 
supervene suddenly when the infant seems to be doing well. In such 
cases there is simply a failure of the circulatory, as well as respiratory 
and nervous functions. Atelectasis which is ascribed to most of these 
cases as a cause of death is present normally in these premature 
infants. The lung has not yet expanded, so that this alone cannot 
be said to cause death. Many of these eases die suddenly in con- 
vulsions. Syphilitic infants though doing apparently well under 



20 INFANCY AND CHILDHOOD. 

treatment may be found dead in the crib, while a few moments before 
this ending seemed improbable. The greatest number of deaths in the 
newborn is certainly found among the illegitimate. This is probably 
due to the neglect which these infants suffer. 

Circulatory Disturbances. — Hemorrhage, either cerebral or in 
haemophilia, is a cause of sudden death in the newborn. Rupture of 
a cerebral artery into the ventricle of the brain is met with after 
difficult labor. Congenital cardiac disease may tend to sudden death; 
thus Rauchfuss describes cases in nurslings as the result of an embolus 
from the ductus Botalli lodging in the pulmonary artery. Aneurysm 
as a cause of death is rare in infancy and childhood, but there have 
been ruptures of such aneurysms without previous symptoms, espe- 
cially in connection with the heart in which aneurysm has resulted 
from interstitial myocarditis. Rupture of an aneurysm of the large 
vessels, such as the aorta, has not been observed during childhood 
though such a case has been noted later in life by Strumpel as a result 
of the rupture of a congenital aneurysm. Carpenter reports the case 
of an infant twelve months of age dying suddenly. The heart was 
found to be the seat of extensive fibroid degeneration. Any form of 
valvular heart-disease may cause sudden death. Erosion of the larger 
bloodvessels is seen as a sequence of retropharyngeal abscess. The 
rupture of the artery in these cases leads to fatal hemorrhage. The 
myocarditic death seen in the course of the infectious diseases, such 
as pneumonia, typhoid fever, typhus fever, scarlet fever, and diph- 
theria, will receive more extended consideration later on. 

Diseases of the Respiratory Tract. — Diseases of the respiratory 
tract are a very important factor. That every case of sudden death 
in the newborn is not the result of overlying or asphyxia has been 
shown above. Marantic infants and children who are suffering from 
bronchopneumonia of a chronic type are prone to die suddenly while 
apparently doing well. I have experienced this quite often, espe- 
cially in hospital practice. A cheesy tuberculous or acutely inflamed 
gland may erode and burst into the trachea and thereby cause sudden 
death by suffocation. A retropharyngeal abscess may cause such a 
death by bursting spontaneously above the larynx. Marantic children 
or those in whom the pharyngeal mucous membrane for various 
reasons has lost its sensitiveness may suffocate through the lodgment 
of food above the larynx or fluids may pass from the stomach into the 
pharynx and thence into the trachea. This has occurred during sleep, 
the infant being found dead in its crib the next day. The rarer 
causes are congenital atresia of the trachea or pressure on the trachea 
by some enlarged lymph-node or a congenital tumor. Such anomalies 
may cause repeated attacks of asphyxia before the final suffocative 
attack. In a majority of a large number of autopsies on infants who 






SUDDEN DEATH AMONG INFANTS AND CHILDREN. 21 

suffered sudden death Kichter found a tracheobronchitis extending to 
the finer bronchioles. In some cases the larger bronchi may become 
plugged with the products of inflammation, thus causing asphyxia. 
Pleuritic exudates of large volume are a cause of sudden death in the 
adult, but not so in the young in whom the right ventricle is capable 
of more effective work and the resiliency of the chest wall is greater. 

Affections of the Central Nervous System. — Affections of the 
central nervous system may lead to sudden death. Thus an undiag- 
nosed cerebral abscess following an otitis may cause the sudden death 
of the individual by bursting into the ventricle of the brain years 
after the otorrhoea has run its course. Such a case occurred to 
Carpenter. Embolism and cardiac disease may result in cerebral 
hemorrhage and sudden death in children in whom no heart lesion 
was previously diagnosed. 

Other Causes. — Among the causes not yet cited are the various 
intoxications in gastro-intestinal disorders or in the forms of sepsis 
in infancy. Especial interest attaches to hyperthermia as a cause of 
sudden death at the outset of the infectious diseases. # Liebermeister 
and Thomas first called attention to high temperature as a cause of 
death. Holt has observed some cases and I have seen sudden death 
with very high temperature follow lumbar puncture in cases of brain- 
tumor. In the case of Thomas the child was of lymphatic constitu- 
tion. Eeer has recently called attention to cases of eczema which 
have been rapidly healed and in which sudden death has supervened 
in the patient who was doing well. Most of these children are also of 
lymphatic status. I have heard Henoch express a fear of sudden 
death after the too energetic and rapid cure of eczema in infants. 

Surgical Causes. — The surgical causes of sudden death are classi- 
fied by Lubby into the circulatory, toxic, infective, mechanical, those 
due to the states of the nervous system, and finally those of rare and 
unusual origin. The extended consideration of all these is not feasible 
and mention may be made only of what seems more important. Fatal 
hemorrhage, in abnormal states of the blood, may occur from the 
umbilicus, the intestine and as the result of the simple extraction of 
a tooth or a circumcision. Thrombosis or embolism may result from 
the injection into the circulation of foreign or toxic agents, as in the 
treatment of na?vi. Cold, exposure, or undue delay in operation may 
be a potent factor. The rapid evacuation of the pleura in a case of 
empyema, or the subsequent irrigation of the pleural cavity, may 
cause sudden death by direct insult to the heart or by the change of 
blood pressure acting in a reflex manner on the vital centers. After 
operations on the peritoneum, as in appendicitis, while the patient is 
apparently very well there may be sudden death resulting front a 
thrombosis of the pulmonary artery or a septic myocarditis. Acme 



22 INFANCY AND CHILDHOOD. 

oedema of various kinds may, if inflammatory and involving the 
air passages, cause sudden death by direct pressure. 

Mycotic infections of all varieties are a cause after surgical oper- 
ation. The mechanical obstruction of the air passages by foreign 
bodies may lead to a sudden exitus and needs no further explanation. 
Operations involving the larger veins by admission of air into the 
circulation are a rare cause. The rapid evacuation of the cerebro- 
spinal fluid may be a cause in the course of operations on the nervous 
system. It should be mentioned that the operation of lumbar punc- 
ture has been followed by sudden death in the presence of a tumor 
of the brain or in infants who are greatly reduced in strength and 
resistance in the course of meningitis or hydrocephalus. Sudden 
death in the various stages of anaesthesia is familiar to the surgeon. 
Recently its frequent occurrence in lymphatic children has been em- 
phasized by Blake. I saw one case of death from cardiac paralysis 
after an anaesthesia in an appendical operation, the cardiac symptoms 
supervening within a few hours after the operation. The appendix 
had been the seat of a mild catarrhal process, but there was no 
peritonitis. The heart-block in this case was characteristic; at the 
wrist the pulse could scarcely be felt, while the action of the heart was 
disordered and rapid, beating over two hundred per minute with no 
effective filling of the arteries. 

Lymphatism. — Finally we may mention the cases of sudden death 
in infants and children which are now exceedingly numerous in the 
literature. They occur in infants and children who are the subjects 
of so-called lymphatism. There may be symptoms of laryngismus 
stridulus, with or without convulsions. There may be rachitis with 
signs of so-called latent tetany or there may be the outspoken signs 
of tetany. Here, the infant or child may have been previously in 
apparent health when a laryngismic attack, provoked by some exami- 
nation of the patient, with or without convulsions, ends life to the 
consternation of the physician. In cases of tetany death may sud- 
denly supervene without any previous symptoms that would warn of 
the impending danger. Post-mortem changes have been found which 
will be described later under the heading of lymphatism. The inter- 
pretation of these changes will be more fully considered under their 
proper caption. 

THE NORMAL INFANT AND CHILD. 

A knowledge of the facts connected with the growth and develop- 
ment of the normal infant and child is essential to the understanding 
of diseased conditions in these subjects. Normal children vary within 
certain limits, as to their body-weight, temperature, pulse, respiration, 



THE NORMAL INFANT AND CHILI). 



23 



and secretion of urine, in a manner similar to sick infants in the 
presentation of symptoms. One child may weigh more or less than 
another of the same age, and still be in excellent health. The 



Fig. 1. 



DAYS 




1 


2 


3 


4 


5 


6 


7 


8 


9 


10 


li 


h- 
I 
O 

t 

3,100 
75 
50 
25 

3,000 
75 
50 
25 

2,900 
75 
50 
25 






































































/ 
























/ 
























7 
























/ 
























1 






















/ 
























/ 
























/ 
























/ 
























/ 
























/ 
























/ 
























/ 






















1 
















































I 
























I 
























/ 
























/ 
























/ 
























/ 














































/ 










\ 














/ 










\ 














/ 










\ 














/ 










\ 














/ 










\ 














/ 










\ 














/ 
























1 












\ 










I 














\ 










/ 














\ 










/ 














\ 










/ 














\ 










/ 














\ 










/ 
























/ 
























1 






















1 






















/ 
























/ 
























/ 
























/ 
























/ 
















' 








/ 
























/ 




















■ 
























/ 




















/ 
















i 




/ 
























J 
























/ 
























/ 
























f 






















1 
























I 






















I 


/ 






















/ 


/ 






















V 

















































































































Normal curve of weight during the first ten days of life. (Budin.) 

physician must take into accoiinl not only the infant itself, but con- 
ditions of heredity and surroundings. There is absolutely no unvary- 
ing picture of a normal child. There are limits of variation, and 
these the physician should endeavor to master. 



24 



INFANCY AND CHILDHOOD. 



Body-weight. — During the first two or three days following the 
birth of the infant there is a loss of body-weight. Usually this loss 
amounts to from 150 to 200 grammes, or 5 to 6^ ounces (Fig. 1). 
It is even greater in some infants. The passage of meconium and 
urine, the exhalations from the skin and lungs, and the small amount 
of nourishment taken by the infant account for this loss. As nursing 
begins the weight increases until the seventh day, when the infant, 
under normal conditions, will have regained its original weight. On 

Fig. 2. 





MONTHS 1 2 3 4 5 6 7 S -9 10 H 12 




DAYS 


| II' 


WEEKS 




1 23456759 10 ll 12 15 


14 A S 12 16' Sol 24 


...? 


5 


52 ._2 


3 1 4 


o La 


43 52 5S 




in rri'i 1 1 m— 


; I'M Ml Ml 


■ 1 1 




XL 




r 




\ ' ! 


| || 1 Ml Ml e 






; 


































vr : a 




,, ■ ' [ ' ■ : ' ; ! 
















• /' \ 4 




















>■ . i& 




















s' : ,2 


















s'' 


.5 


















/ 






l0 i i ! : ; 


, , j , 












s 


'6 
















! , 


S 


! 12 
















Lt-T 




8 




m : ' : 
















, -* 




'3 I'll 
















16 




















12 








1 
















ir 






















■ ' : ' ; 


















1 1 ' 
















i2 






' : : ■ ■ 














a 




17 ■ 














































/ 










'2 










/ 










1 S 










/ 














16 










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l 






■2 








/ 












s 




15 ; M 1 ' 




/ 












4 CI 


























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3q 






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1 a 7 






■ ; 1/ ' 














■ 4 T 






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,6 3 




















■2 U 


1? 




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! M : : ; / 












1 


i i i i ' ' ' ' 2 






1 ' : ' : / i '1 














i 9 


























i ; ■ / 














.s 






1 1 : / 




















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■ 6 






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i / 








































i? 1 1 1 1 1 1 IN 




















/ ■ i : 




















/ 










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16 






/ I ! i 1 














'2 






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12 






-1-4- ■■■■■!■ 














a 




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13 


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12 y 
















2 




m - s : 




















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7 4 v 


X X 














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6 3 




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i ! 








































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13 












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12 




: 












12 3 




















" n 





















1 io 


». 


6* 


_ —_ jj 


1 ! I 


: 










^ -j__l. a .. 



Author's chart showing the average weight of breast-fed infants from birth to the 

of the fifty-second week. 



end 



the tenth day the infant weighs 100 grammes, or 3J ounces, more 
than at birth. 

In some cases, if the infant is placed immediately after birth on 
a breast which secretes milk abundantly, it will not lose any, or but 
little, weight. 

In an investigation by Gundling it was noted that many infants 



THE NORMAL INFANT AND CHILD. 25 

ceased to lose in weight after the second day, and an almost equal 
number on the third day. Boys lost more than girls, and the infants 
of multipara? less than those of primiparse. The average entire loss, 
however, was about 241 grammes. Most infants regain their original 
weight on the ninth day. The average infant, according to Camerer, 
at birth weighs 3450 grammes; and according to Budin there is a 
physiological loss of the amount indicated above, which is rapidly 
regained from the seventh day on, when the weight rises in a physio- 
logical curve throughout the remainder of infancy. 

From the second week to the fourth month an infant gains 1 
ounce (30 grammes) daily, or 1^ to 2 pounds a month, the latter in 
the first two months ; from the fourth to the sixth month it will gain 
i to S of an ounce daily (17 to 20 grammes), or about a pound a 
month. From the sixth to the twelfth month the infant gains J 
ounce daily (15 grammes), or a pound a month. 

An infant at the sixth month should weigh twice its initial weight ; 
and at the end of the twelfth month a normal infant should weigh 
20 to 21 pounds, or 9000 to 9800 grammes (Fig. 2). 

Within physiological limits the weight given above will vary, 
and there are normal infants who may weigh a pound less or a pound 
more than the figures given. This is accounted for by variation in 
the size of the skeleton, so that we cannot fix an absolute weight of 
20 or 21 pounds as the normal weight of an infant at the end of 
twelve months, but only as an average weight. 

Increase of weight differs also in artificially fed (bottle-fed), as 
compared to breast-fed, infants. The quantity of milk necessary to 
maintain nutrition is greater than in the case of the breast-fed infant. 
There is always the danger of overfeeding an infant on the bottle. 
The increase in weight is not so regular as in the breast-fed infant, 
as is shown in the following table : 



n 



Camerer 



Weeks 1—2 2—4 4—8 8—12 12—16 16—20 20—24 
ncrease 4 21 21 22 22 25 22 

Weeks 24—28 28—32 32—36 36—40 40—52 

Increase 13 16 16 9 12 

I Months 1 2 3 4 5 6 7 8 9 10 

[ Weight 3810 4430 5090 5800 6550 7180 7650 8140 8600 8880 

^ ,., f Months 12 3 4 5 6 7 8 9 

jvopiiK ^ Weight 3735 5068 5285 5518 7688 7223 8680 9021 

In the table above and that on p. 20 are shown in grammes not only 
the irregularity in the daily increase, but also the irregularity in the 
total weight. My own eases were examined with a view to deter- 
mining what an artificially fed babv weighs it' it is thriving. The 
figures correspond closely to those given by Camerer. 



26 



INFANCY AND CHILDHOOD. 



The following table shows in grammes the daily increase of weight 
of the breast-fed and the bottle-fed infant : 



Months. £2EH 

(breast;. 

1 31 

2 26 

3 24 

4 21 

5 18 

6 .... 15 

7 15 

8 16 

9 9 



Camerer 


Koplik 


(bottle). 


(bottle). 


21 


32.0 


22 


17.4 


22 


236 


25 


18.0 


22 


14.2 


13 


11.8 


16 


15.6 


16 


15.1 


9 


— 



Length of Body. — At birth an infant measures from 49 to 50 
cm. (19|— 19f in.) in length; boys on the average have a greater 
length than girls. During the first year the increase in length is 20 
cm. (Tg- in.). Thus, at the end of the fifteenth year the length of 
the body has increased 100 cm. (39^ in.). 

Head. — Herz, in a number of measurements of the head of the 
newborn infant, found that the 



Average circumference of the head was 

Sagittal diameter 

Large transverse diameter .... 



39.2 cm. (15.6 in.). 

11.1 cm. ( 4.4 in.). 

9.0 cm. ( 3.6 in.). 



The latest measurements of the head of infants, beginning at birth 
and extending to the twenty-fourth month, were made by Hrdlicka 
and Pisek, under the guidance of Dr. Chapin. These measure- 
ments are applicable to American-born infants, and are probably 
the most reliable we have. (See table below.) 



Circumference ] 


of the Head. 




Age. 


Male. 


Female. 


1st day to end of 1st month < 

5th to 6th month j 

11th to 12th month . j 

22d to 24th month j 


35.1-38.3 cm. 
13.8-15.1 in. 

40.5-43.9 cm. 
16.0-17.3 in. 

44.7-45.3 cm. 
17.6-17.8 in. 

47.6-49.0 cm. 
18.7-19.3 in. 


33.4-37.1 cm. 
13.1-14.6 in. 

41.7-44.6 cm. 
16.4-17.6 in. 

43.7-46.3 cm. 
17.2-18.2 in. 

45.6 cm. 
18.0 in. 



The newborn infant has a formation of the caput succedaneum 
and in some cases of a cephalohoematoma, which will be treated of 
in a separate section. The fontanelles, however, are of importance 

1 The circumference is taken just above the glabella in front and the external 
occipital protuberance behind. 



TEE NORMAL INFANT AND CHILD. 27 

and may be spoken of in this connection. They are causer) by the 
apposition of the cranial bones — the parietal, frontal, and occipital 
— which at first are circular, and at the points of non-contact form 
triangular spaces, the fontanelles. These spaces are at first closed by 
membrane only. At birth, or soon thereafter, the posterior fontanelle 
closes ; the anterior fontanelle, however, remains open. The time of 
closure of the anterior fontanelle is of the utmost clinical importance. 
Kassowitz and Hochsinger contend that the anterior fontanelle grows 
smaller from birth to the end of the first year, and closes at from the 
twelfth to the fourteenth month. Elsasser and Rhodes, however, con- 
tend that, while the lateral and posterior fontanelles close during the 
first months of infancy, the anterior fontanelle increases in its longi- 
tudinal and transverse diameters with the growth of the cranium up 
to the twelfth month. Most writers, however, are inclined to accept 
the view of Kassowitz and Hochsinger. If the closure of the anterior 
fontanelle is delayed until the fifteenth month, we may look upon it 
as a sign of rachitis. 

Respiratory Functions.— Shape of the Chest. — The ribs of some 
infants are quite apparent to the eye, while those of others are con- 
cealed by a panniculus of fat. The normal chest in the child has not 
the shape it assumes later in life— that of a truncated cone. The 
later portions are quite straight and parallel. The chest is not 
flattened anteroposteriorly to the same extent as in the adult. In the 
newborn infant the transverse diameter of the thorax is twice that of 
the anteroposterior diameter; whereas in the adult it is three times 
its length. In infants the superior border of the manubrium sterni 
is on a level with the midsection of the first dorsal vertebra ; in the 
adult it is lower by a body and a half of a vertebra. The tendon 
of the diaphragm is horizontal in the newborn infant, and will be 
found to be on a level with the disk between the eighth and ninth 
dorsal vertebra?. A rachitic chest may be pointed at the sternum, 
forming what is called a chicken-breast. Some rachitic chests show 
a. marked flaring of the lower ribs, with a lateral incurvation above 
this flaring; or they are flattened at the sides and deeper at the 
sternum. The sternum may be the top of a truncated cone, a varia- 
tion from the normal state. Infants and children who have had 
several attacks of bronchitis and who have emphysema of the lungs 
show a marked fulness at the upper part of the chest, underneath 
the clavicles. 

Chest Circumference. — The following measurements of chesl cir- 
cumference are important as showing the development of American- 
born infants from birth to the twenty-fourth month, and wore made 
bv ITrdlicka and Pisek: 



28 



INFANCY AND CHILDHOOD. 



Chest Circumference. 



Age. 


Male. 


Female. 


1st day to end of 1st month < 

5th to 6th month < 

11th to 12th month . . -< 


32.0-36.7 cm. 
12.6-14.4 in. 

39.9-43.3 cm. 
15.7-17.0 in. 

43.4-45.1 cm. 
17.1-17.8 in. 

42.1-47.7 cm. 
16.5-18.8 in. 

50.7-50.8 cm. 
19.9-20.0 in. 


30.0-35.9 cm. 
11.8-14.1 in. 

38.6-43.2 cm. 
15.2-17.0 in. 

42.8-48.3 cm. 


13th to 14th month i 

23d to 24th month < 


16.9-19.0 in. 

45.1-49.4 cm. 
17.8-19.0 in. 

47.1 cm. 




18.5 in. 



Normal Number of Respirations. — The normal number of respira- 
tions in infants and children are as follows : 



Immediately after birth 44 per minute. 

From the 1st to the 2d month 24-36 " 

2d " 5th " 20-32 

6th " 10th year 20-28 



The character of the respiratory movements in infants and chil- 
dren is quite shallow and irregular, especially in sleep, as compared 
to the adult. Eespiration is of the diaphragmatic type up to the 
tenth year in the female child, and the eleventh year in the male, when 
it takes on the regular type of respiration seen in the adult. 

Chemism of Respiration. — Infants nourished upon the mother's 
breast excrete less C0 2 than adults (Kubner, Heubner, Bendix). 
Thus, a baby weighing 5 kilos (11 pounds) exhales 13.5 C0 2 per 
square metre of surface; whereas the adult exhales per square metre 
15.3 to 16.5 C0 2 (Eubner). On the other hand, the breast-fed 
child excretes a greater amount of water by way of the skin and 
lungs than the adult, on account of increased respiratory action, 
general activity of the infant, and its warmer apparel. 

The bottle-fed baby excretes a greater amount of C0 2 and water 
by the skin and lungs than the breast-fed baby. This is explained 
by the fact that the bottle-fed infant consumes in its food a greater 
amount of nitrogen than the breast-fed infant. 

Circulation and Pulse. — ■Circulation. — According to the investiga- 
tions of Vierordt, the circulation in the newborn infant is completed 
in 12 seconds; in the child of three years, and up to the seventh 
year, in 15 seconds; in the child of fourteen years, in 18 seconds; 
and in the adult, in 22 seconds. 



TEE NORMAL INFANT AND CEILD. 



29 



Table of the Average Height, Weight, Head Circumference, and Chest 
Measurements of American Boys and Girls. 



Boys- 



(Collated 


from thousand 


s of childrer 


in various States by Bowditch, 


Burk 


, MacDonald 


and 








Hastings.) 
















Years 
of age. 


Sex. 


Height. 


Weight. 


Head 
circum. 


De 
of c 


pth 

hest. 


Breadth 
of chest. 


Chest ex- 
pansion. 






In. 


Cm. 


Lbs. 


Kilos. 


In. 


Cm. 


In. 


Cm. 


In. 


Cm. 


In. 


Cm. 




f Boys, 
t Girls. 


41.7 


105.9 


41.6 


18.9 


20.1 


51.2 


4.9 


12.3 


7.1 


18.1 


1.3 


3.4 


53^. 




41.3 


104 9 


40.7 


18.5 


19.7 


50.2 


4.8 


12.3 


7.0 


17.7 


1.4 


3.5 






/Boys, 
t Girls. 


43.9 


111.9 


45.2 


20.5 


20.2 


51.5 


5.0 


12.8 


7.2 


18.4 


1.6 


4.2 


&A- 




43.3 


109.0 


43.4 


19.5 


19.8 


50.3 


4.9 


12.3 


7.0 


17.7 


1.5 


3.8 






/Boys. 
[Girls. 


46.0 


116.8 


49.5 


22.5 


20.4 


51.9 


5.1 


12.9 


7.4 


18.9 


1.8 


4.5 


?K- 




45.7 


116.0 


47.7 


21.6 


20.0 


50.9 


4.9 


12.5 


7.2 


18.4 


1.8 


4.o 






' Boys. 


48.8 


123.9 


54.5 


24.4 


20.5 


52.2 


5.1 


12.8 


7.6 


19.4 


2.3 


5.9 


&A> 




1 Girls. 


47.7 


121.1 


52.5 


23.8 


20.2 


51.2 


4.9 


12.5 


7.4 


18.9 


2.0 


o.U 


9H- 




(Boys. 
(Girls. 


50.0 


127.0 


59.6 


27.0 


20.6 


52.4 


5.2 


13.2 


7.8 


19.7 


2.5 


«..-» 




49.7 


126.2 


57.4 


26.0 


20.4 


51.9 


5.1 


13.1 


7.0 


19.3 


2.2 


o.6 






/ Bovs. 

| Girls. 


51.9 


131.8 


65.4 


29.5 


20.6 


52.6 


5.2 


13.2 


8.0 


20.2 


2.V 


7.0 


io%. 




51.7 


131.3 


62.9 


28.5 


20.5 


52.0 


5.1 


13.0 


7.8 


19.8 


2.4 


6.0 






/Boys. 
(Girls. 


53.6 


136.1 


70.7 


32.2 


20.8 


52.9 


5.4 


13.8 


8.2 


20.9 


2.9 


7.3 


liH- 




53.8 


136.6 


69.5 


31.5 


20 7 


52.5 


5.2 


13.1 


8.0 


20.3 


2.6 


6.6 


12%. 




/Boys. 
(Girls. 


55.4 


140.7 


76.9 


34.9 


21.0 


53.3 


5.6 


14.1 


8.5 


21.5 


3.0 


'/.S 




56.1 


142.5 


78.7 


35.7 


20.9 


53.0 


5.4 


13.8 


8.4 


21.0 


2.4 


6.2 


13%. 




J Boys. 
( Girls. 


57.5 


146.0 


84.8 


38.5 


21.1 


53.5 


5.6 


14.3 


8.7 


22.1 


3.2 


8.2 




58.5 


148.6 


88.7 


40.3 


21.0 


53.5 


5.5 


14.1 


8.7 


22.1 


2.6 


6.6 


14%. 




/Boys. 


60.0 


152.3 


95.2 


43.2 


21.3 


54.1 


5.9 


15.0 


8.9 


22.7 


3.3 


8.4 




1 Girls. 


60.4 


153.4 


98.3 


44.6 


21.3 


54.1 


5.7 


14.5 


9.0 


22.9 


2.7 


6.8 






/Bovs. 


62.9 


159.7 


107.4 


48.8 


21.4 


54.5 


6.3 


16.0 


9.3 


23.6 


3.3 


8.4 


15%. . . 


t Girls. 


61.6 


156.4 


106.7 


48.5 


21.5 


54.6 


6.0 


15.3 


9.5 


23.8 


2.6 


6.5 



Table of Weight, Length, Head Circumference, and Girth of Chest 
from Birth to the End of the Fourth Year. 



Age. 



Birth . . . 

6 months 
12 months 

2 years . . 

3 years . . 

4 years . . 



Sex. 


Length. 


Weight. 


Head 
circum. 


Ch( 

girt 




In. 


Cm. 


Lbs. 


Kilos. 


In. 


Cm. 


In. 


/Bovs. 
\Girls. 


19.7 


50.0 


7.4 


3.45 


13.8 


35.1 


12.6 


19.3 


49.0 


7.1 




13.1 


33.4 


11.8 


/Boys. 
1 Girls. 


25.4 


64.8 


16.0 


7.2 


16.0 


40.5 


15.7 


25.0 


63.6 


15.5 


7.0 


16.4 


41.7 


15.2 


/Boys. 
\Girls. 


29.5 


73.8 


21.5 


9.8 


17.8 


45.3 


17.8 | 


28.7 


73.2 


21.0 


9.5 


18.2 


46.3 


19.0 


/Bovs. 


33.8 


84.5 


30.3 


13.8 


19.3 


49.0 


20.0 ; 


\Girls. 


32.9 


82.8 


29.2 


13.3 


18.0 


45.6 


18.0 


/Boys. 


37.0 


92.6 


34.9 


15.9 


19.3 


49.0 


20.1 1 


1 Girls. 


36.3 


90.7 


33.1 


15.0 


19.0 


48.4 


19.8 


/Boys. 
\Girls. 


39.3 


98.2 


37.9 


17.2 


19.7 


50.3 


20.1 


38.8 


97.0 


36.3 


16.5 


19.5 


49.6 


20.5 



Cm. 
32.0 
30.0 
39.y 
38.6 
45.1 
48.3 
50.8 
48.0 
51.1 
50.5 
52.8 
52.2 



Pulse. — Its Rapidity. — The following is the rapidity of the pulse 
at the various ages of infancy and childhood given by Bednar : 



Beats per minute. 

Foetus 108 to 100 

First two minutes of life 72 to 94 

Fourth minute of life 140 to 208 

Eighth day to second month 00 to 130 

Second month to twenty-first month 96 to 120 

Second to fifth year 92 to 108 

Fifth to eighth year 84 to 100 

Eighth to twelfth year 70 to 96 



The pulse-respiration ratio in infants is as 



d or 5 



to 1. The 



respiration in these little subjects being- 30 to 32 a minute, the ratio 
of the respiration to pulse will be as 1 to 4 in infancy; 1 to 5 or 6 



30 INFANCY AND CHILDHOOD. 

in the second year. Turning, crying, coughing, or any excitement 
will increase the pulse-beat 15 to 30 a minute. During sleep the 
pulse varies from 15 to 20 beats per minute. After the third month 
the pulse is more rapid in girls than in boys. 

Rhythm of the Pulse. — The rhythm of the pulse has been the sub- 
ject of much investigation by various observers; the following are the 
main peculiarities of the normal pulse : 

(a) In infants and children the pulse is normally arrhythmic or 
irregular, both in regard to time intervals and its relation to what is 
known as the respiratory curve in sphygmographic tracing. 

(b) Dicrotism is a normal characteristic of the pulse in infancy 
and childhood. The irregularity of the pulse in some infants and 
children is not very marked; in others this irregularity becomes 
more apparent under the influence of undue excitement. Dicrotism, 
although very evident and due to the great arterial elasticity in normal 
children (Landois), is never as marked as in children who are the 
subjects of cardiac disease, pertussis (heart strain), or acute infection 
(typhoid fever). On the whole, it may be said in regard to the 
pulse, that it is more subject to variability as a result of slight 
influences than that of the adult. 

Body-temperature. — The temperature of the newborn infant will 
vary from 36.9° to 38.4° C. (98.4°-101.1° F.). The latter is excep- 
tional. According to the studies of Lachs, the average temperature 
of the newborn infant varies from 37.5° to 37.9° C. (99.5°-100.2° 
F.). After the first bath the body-temperature falls 1.7° to 2.5° F. 
Two hours after the first bath the temperature begins to rise, and 
reaches its initial height within twenty-four hours, or sometimes 
later. In premature or weakly infants the 'temperature does not 
reach its original height for fully three days, and in some instances 
it may never reach the original height. 

The body-temperature of infants shows slight fluctuations during 
the day which are quite normal. The maximum temperature in 
most cases is reached at midday or during the afternoon; the mini- 
mum, during the morning and evening. The daily fluctuations vary 
from 0.1° to 0.3° F. The daily fluctuations of temperature are 
more regular and uniform in the breast-fed infant as compared to 
the bottle-fed infant (Marfan). During sleep the temperature may 
sink from 0.3° to 0.5° F. (Alix and Vierordt). In a general way we 
may say that in infants and children any rectal temperature ranging 
from 99.3° to 100° F. is normal. 

Crying, excitement, or exercise will raise the temperature in 
infants and children from one-half to several degrees. I have seen an 
instance of a boy, seven years of age, with a normal temperature, 
observed throughout the course of two or more years, of 100.5° F. at 



THE NORMAL INFANT AND CHILD. 31 

midday, which would rise 1° F. in the rectum after five minutes' 
exercise. This boy was otherwise in perfect health. 

The following table of body-temperatures (rectal J is the result 
of the investigations of Lachs, Vierordt, and Alix : 

Newborn infant 37.5° to 37.9° C. (99.5°-100.2° FA 

5-16 months 37.4° to 37.9° C. (99.3°-100.2° R). 

20 months-4 years 37.5° to 37.9° C. (99.5°-l 00.2° R). 

5-9 years . 37.6° to 37.8° C. (99.6°-100.1° R). 

Heat Calories. — Children, according to Vierordt, produce more 
heat calories, per kilo of body- weight, in the twenty-four hours than 
do adults; thus, in children there are 130,681 calories per kilo 
produced as compared to the adult, where we find 39,640 calories. 
If, on the other hand, we accept the investigations of Kubner, in 
which the calories are calculated per square metre of body-surface, 
the infant does not use up any more calories than the adult: 1050 
to 1200 as compared with 1300. The infant, for its size, therefore 
gives off more heat from the body-surface, and is therefore more 
sensitive to loss of heat than the adult. 

Urine. — -Physical Characteristics. — The urine up to the eighth day 
of life is dark in color, contains epithelial cells, leucocytes, and uric 
acid crystals. After the eighth day the urine is a limpid, clear, 
colorless fluid. The urine of artificially fed infants is somewhat 
darker than that of breast-fed infants, and especially is this so in 
any disturbance of the functions of the intestine. If there is jaundice 
the urine may contain biliary pigment. 

The urine has a resinous odor, as in the adult. The specific 
gravity during the first three days of life ranges from 1010 to 1012 ; 
after the tenth day, when the infant has partaken of liquid food, the 
specific gravity falls to 1003 or 1004. It frequently happens that 
the newborn infant does not pass urine on the first or even the 
second day of life. This is sometimes misinterpreted as due to 
some obstruction, either in the ureters or external genitals. From the 
second to the tenth day the infant voids urine two to three times in 
the course of the twenty-four hours. Huge and Robin found that ar 
the third month the infant voids urine ten to eleven times in the 
twenty-four hours, passing 400 to 500 grammes in that time; at the 
fifth month, 400 to 500 grammes daily ; from the second to the third 
year, 500 to 600 grammes; from the third to the fifth year, 750 
grammes; and from the seventh to the tenth year, 1200 grammes 
daily (Parrot and Eobin). 

The following table gives not only the quantity of urine passed 
during early infancy and childhood, but shows the difference in 
amounts passed by the breast-fed and the artificially fed infant. 



32 



INFANCY AND CHILDHOOD. 



It will be seen that, owing to the larger gross quantity of fluids 
taken into the body by the artificially fed infant, the amount of 
urine passed is greater than that of the breast-fed infant. The 
amount of urine is also dependent on the composition of the food. 
Camerer has shown that, as a rule, every 100 grammes of liquid food 
will yield 68 grammes of urine. 



Daily Quantity of Urine (Reusing). 

Breast. Bottle. Specific gravity. 

1st day 8.4 35.8 1010 

2d " 26.8 71.0 1010 

3d " 40.9 135.8 1010 

4th " 60.8 187.0 1010 

5th " 119.1 283.0 1005 

7th " 157.0 325.0 1005 

8th " 208.0 406.0 1005 

30th-150th day 350)^ Q , 1ft19 

150th-325th" 425/ lsrea&t W 

2d year 675 1012 

3d-5th " 600-1200 1010-1012 

6th " 1295 1012 

10th " 1866 1010 



The infant passes live or six times as much urine per kilo of 
body-weight as the adult; the child, three or four times as much. 

Urea. — Urea is excreted in greater quantities by the artificially 
fed infant and the infant fed by a wet-nurse than by infants fed at 
the mother's breast. Reusing found that in the infant at the mother's 
breast the amount of urea increases from the first to the third day, 
when it is highest. The reason of the diminished excretion of urea 
at this period lies in the fact that there is an insufficiency of food 

Daily Amount of Urea. 

Breast-fed. Bottle-fed. 

1st day 0.06 0.33 

2d " 0.26 0.40 

3d " 0.52 0.67 

4th " 0.50 0.55 

5th " 0.78 0.65 

6th " 0.79 0.61 

7th " 0.81 0.88 

30th-150th day 0.94 

2d year 9.87 

3d-5th " 13.9 

10th " 20.4 



during the first days of life. The tissues of the body are burnt up 
in the processes of metabolism, hence there is a diminution of weight. 
Inasmuch as the body is rich in fat, this is burnt first and nitrogen is 
saved. As a result, the nitrogen excretion in the first days is less 
than it is later, when sufficient food makes up for the loss of body- 



THE NORMAL INFANT AND CHILD. 66 

weight. Added to this fact of insufficiency of food, there is a paucity 
of fluid nourishment during the first days, causing a retention in the 
body of the end-products of metabolic processes. After the first few 
days in the newborn infant, as in all cases of starvation, there is an 
increase of nitrogen excreted until by means of increased food metab- 
olism attains its equilibrium and urea is excreted in normal quantities. 

Albumin. — Albumin is found in the urine, according to Flens- 
burg, in 40 per cent, of newborn infants. He attributes its pres- 
ence to the existence of uric acid infarction in the kidney at this 
time. Other authors contend that albumin is not present normally 
in the urine of infants, but if the mother has during labor suffered 
from eclampsia, the urine of the newborn infant may contain albumin 
and casts. Czerny regards the whole question of albuminuria in 
the newborn as sub judice, inasmuch as in the cases investigated, 
including those of Flensburg, no mention has been made of or con- 
sideration given to disturbances of the functions of the intestine or 
other abnormal conditions which might have been present at that time, 
and he is inclined to believe that if such consideration were given, 
it would be found that the appearance of albumin in the urine of 
infants is in some way connected with the disturbances of the func- 
tions of the intestine. 

Indican. — Indican is not present in the urine of the healthy breast- 
fed infant; whereas it is found in traces in the urine of artificially 
fed infants, even in the absence of any disease. It is especially con- 
stant in the urine of infants suffering with gastro-enteritis, and may 
be present in the urine of infants suffering from a number of mal- 
adies, especially forms of suppuration. It is present in the urine of 
infants suffering from tuberculosis, but is not pathognomonic of that 
affection (Zamflresco). 

Acetone. — Acetone is present in small quantities in the normal 
urine of infants and children, and is found also increased in quan- 
tity in the case of fevers, such as the exanthemata, or pneumonia. 
The amount of acetone increases in proportion to the height of the 
fever. It disappears or diminishes to the normal quantity with the 
disappearance of the fever. It is enormously increased in the urine 
of children during a seizure of eclampsia. It is not, however, the 
cause of the eclamptic seizure, as has been supposed. The cause of 
acetonuria is not clear. It is due neither to the hindrance of respi- 
ration nor to fermentation in the stomach or intestine; bur is prob- 
ably due to splitting U p of the nitrogenous substances of the bod v. 
inasmuch as it is increased by a nitrogenous diet, and may be caused 
to disappear by an exclusively carbohydrate diet (Hammarsten). 

Diacetic Acid. — Diacetic acid is not a physiological constituent of 
the urine, but occurs chiefly under the same abnormal conditions as 

3 



34 INFANCY AND CHILDHOOD. 

acetone. There are cases in which acetone but no di acetic acid ap- 
pears in the urine. Diacetic acid is often found in the urine of 
children suffering from fever, such as the exanthemata. Inasmuch 
as diacetic acid is readily decomposed into acetone, it is probably 
an intermediate product in the oxidation of /?-oxybutyric acid in the 
organism. Acetone, diacetic acid, and /3-oxybutyric acid stand in 
close relationship to one another. 

Urobilin. — Urobilin is absent from the urine of the breast-fed 
infant, but is found in traces in the urine of artificially fed infants 
(Giarre and Czerny). 

Dextrose. — Dextrose is found in traces in the urine of infants, as 
it is in that of adults. Dextrose is not found in the urine of healthy 
infants, and only appears in the urine of infants suffering from 
gastro-intestinal disturbances who at the same time may be taking 
food rich in glucose or maltose (Koplik). 

Casts. — Hyaline and epithelial casts may be found in small num- 
bers in the urine of the newborn infant. 

Uric Acid Infarction. — Yirchow has described these infarctions in 
the kidneys of newborn infants. They consist of red or brownish- 
red structures, which on section of the kidney are seen to be depos- 
ited in the pyramids of the organ, stretching from the papilla of the 
pyramid halfway, rarely extending to the border of the medullary 
portion of the organ. They exist in the kidneys of the newborn 
infant, reach the height of formation on the second, and are not 
found after the sixth day. In the newborn infant there is a hyper- 
leucocytosis, which is more pronounced in those cases in which the 
cord has been tied late. 

The quantity of uric acid in the urine of the newborn is much 
greater than it is later. In the tubules of the kidney there is an 
accumulation, especially in the tubuli contorti, of a hyaline sub- 
stance which is the result of cell production. In this hyaline sub- 
stance are deposited crystals of uric acid, and it is in this way that 
the infarctions are formed. The increased uric acid is in some way 
connected with the hyperleucocytosis above mentioned ; the leucocytes 
are disintegrated and uric acid thus produced. It has not been ex- 
plained, however, why there is an increased elimination of uric acid 
with resulting infarctions at this period and not later in infancy. 

MENTAL AND PHYSICAL DEVELOPMENT OF THE INFANT. 

It is not our purpose to enter into every detail of the development 
of the senses of the infant, for this would scarcely be called for in this 
section. On the other hand, there are certain important facts which 
are of great utility to the physician in his daily clinical work. 



MENTAL AND PHYSICAL DEVELOPMENT OF INFANT. 60 

Sight. — On the second day the eyes are sensitive to light. On the 
twenty-first the eye will follow a light; and at the beginning of the 
second month the infant will notice bright colors. At the third month 
the infant will recognize a familiar face. At the sixth month the 
infant will ^definitely recognize its parents apart from strangers. 

Hearing. — A newborn infant is deaf. This is due, it is supposed, 
to the blocking up of the Eustachian tubes with mucus. On the 
fourth day there are evidences of hearing, which develop from this 
time to the fifth week, when loud talking or noises in the room dis- 
turb the infant. At the sixth month the infant will recognize noises 
as to their varying tone. 

Taste. — The sense of taste is not fully developed until the sixth 
month. From the fourth day, however, an infant will show a prefer- 
ence for sweetened, as compared to unsweetened, dilutions of milk. 

Feelings of Pleasure. — An infant will show decided pleasure at 
the sight of playthings at the fifth month, but can hardly be said to 
take an intelligent interest in any object before this time. 

Power to Hold the Head Upright. — The newborn infant cannot 
hold its head upright, and when held in arms the head will sway 
from side to side. The power to hold the head upright is not fully 
developed until the fourth or fifth month. This is important clinic- 
ally in connection with certain diseases, such as amaurotic idiocy, 
the development of which is attended with a loss of power to hold 
the head upright. 

Sitting. — The infant will make the first attempt to sit up at the 
fourteenth week ; but is unable to sit upright without assistance until 
the forty-second week. 

Standing. — The first attempt to stand without support is made 
by the infant at the tenth month. In the eleventh month the infant 
may not only stand, but even stamp its foot. Walking and standing 
are delayed by rachitis. In such cases the infant may even cry if 
placed on its feet, on account of the pain such children experience in 
the bones. 

Crawling and Walking. — The infant will crawl on all fours in 
the fifth month. Attempts to walk begin at various periods, some 
infants being more precocious in this respect than others. The ear- 
liest attempts to walk are made in the tenth month. At the four- 
teenth month an infant will walk if held by the hand. It will si and 
alongside a chair in the fifteenth month, and in the seventeenth 
month a child will walk unsupported. 

Laughing. — An infant two months of age may bo caused to laugh 
in a purely reflex fashion by gentle titillation at the corners of the 
mouth or on the chin. An intelligent laugh, however, is not observed 
until the sixth month. 



36 INFANCY AXD CHILDHOOD. 

Kissing. — Kissing involves the act and the understanding thereof, 
and these are seen combined only quite early in childhood — the 
twenty-third month. 

Memory. — True memory is observed first in the tenth month, 
when the infant will recognize the face of the parent after a short 
absence. In the twenty-first month the child will recognize its 
parents after a protracted absence. 

Speech. — On the forty-third day the infant may articulate unin- 
telligible sounds. At the fourteenth month it will be able to say 
mamma and papa ; and at the end of the second year the child 
attempts the formation of simple sentences. In a general way, it 
may be said that the infant will show signs of intelligence, includ- 
ing sight, hearing, and vocal effort, at about the seventh month, and 
will first attempt to walk at the tenth month. There will be, of 
course, a wide variation in different infants in the development of 
the senses ; and yet we will always recognize as pathological the 
vacant stare, a total lack of utterance, an indifference to bright 
objects, and an inability to stand on the mother's knee, or to hold 
the head upright at the seventh month, especially if other abnor- 
malities, such as protruding tongue, are present. 

METHODS OF EXAMINATION. 

History Taking. — History taking is an art which may well be 
cultivated by the physician, for in a detailed history are often foimd 
the clues to an obscure case. The mother or nurse of the infant or 
child is the best observer of his various conditions, and the physician 
should not lightly reject any facts given to him by an anxious mother. 

The physician should not approach his patient with any pre- 
conceived notion of the malady, but should allow the disease to unfold 
itself with all its symptomatology; he should also have a definite 
routine of examination. 

Maternal History. — The details of maternal history are exceed- 
ingly important, especially as regards miscarriages or difficulties in 
labor. The difficulties in feeding of other children; the details of 
their illnesses ; the presence of disease in any collateral branch of the 
family, especially any nervous disorders, are extremely important. 
The occurrence of a similar affection in other children of the same 
family are of moment; and in older children the various steps of 
development of the senses, such as sight, hearing, speech, and walk- 
ing, are, in nervous affections, of pertinent moment. 

In an infant the history of feeding in all its details is quite 
essential. The condition of the bowels, the presence or absence of 
vomiting, and in older children the historv of dentition are of col- 



METHODS OF EXAMINATION. 37 

lateral interest. A previous history of scarlet fever, measles or 
diphtheria may have a bearing on some nephritic affection in the 
patient, and pains in bones and joints, as well as muscular pains may 
explain cardiac murmurs. The mother very frequently ventures in- 
formation as to previous operations on the tonsils, or adenoids, which 
may be of use as a guide in the case. 

Parental History. — The details of the parental history as regards 
the occurrence of tuberculosis, rheumatism, or nervous disorders are 
of importance. The tendency of other children in the family to 
eclampsia are facts of value. Having elicited the details of the 
previous history the physician proceeds to obtain the minutiae of the 
present illness. His routine will vary essentially as to whether his 
patient is an infant or child of advanced age. In an infant the feed- 
ing in all its details, and its successes and failures are of great im- 
portance. In older children these facts though essential are only of 
collateral interest. 

Onset of Illness. — This is of import, especially as to whether the 
onset was abrupt or acute or slow and insidious. In the great ma- 
jority of cases an illness in infants begins with fever, chill, cyano- 
sis, or vomiting. One of these symptoms may be present to the 
exclusion of the others, or they may all be present, or the illness 
may be ushered in with a convulsion. The condition of the patient 
immediately following the initial symptom constitutes the initial 
stage of the illness. Fever or unconsciousness may follow a chill or 
convulsion, or the patient may after the initial symptom develop an 
eruption, cough, dyspnoea, or pain. The fever may subside in a 
few hours, and the temperature return to normal, with a subsequent 
rise, preceded by a chill, cyanosis, or a second convulsion. Older 
children may complain of pain, as adults do. In the case of an 
infant, pain in the chest or abdomen may be indicated by an increase 
in the number of respirations or a sighing or moaning with each 
effort at respiration. 

The vomiting of the initial stage of the illness may not be 
repeated, or it may recur and form a leading feature. The nature 
of the vomited matter is important. It may have an acid reaction 
or odor, or may consist of stomach contents mingled with biliary 
pigment. It may be streaked with blood. In serious continued 
vomiting it may assume a fecal character. Vomiting may occur 
with the ingestion of food or independently of it. 

The amount of the stomach contents and especially whether this 
seems to those in charge of the infanl more or less than the amount 
taken in at the individual nursing should be noted. 

The condition of the bowels is of importance. The movements 
may be numerous but of normal consistency and odor, or thev mav 



38 INFANCY AND CHILDHOOD. 

be diarrhoeal and have abnormal features. The movements may be 
accompanied by tenesmus or prolapse of the gut. The urine of 
sick infants is sometimes not passed for hours. The mother will 
make a note of this fact. The character of the urine is next to be 
ascertained. Its passage may be painful. The urine may stain the 
diaper yellow (jaundice) or red (lithiasis) ; it may contain blood. 
Older children may be required to pass the urine. The quantity is 
more easily estimated in older children than in infants. With the 
latter we should be cautious in drawing conclusions as to the daily 
amount. In taking a history as above, it is essential, while eliciting 
the main features of an illness, not to inquire concerning unimpor- 
tant details. The main features of the history should be grasped 
and completed in all their minutiae. 

Taking the Status Praesens. — It often happens that the infant or 
child is asleep during the first portion of the visit. Under that con- 
dition the respirations and pulse, with the character of each, can 
be noted. The posture during sleep, the expression of the face and 
its contour, the position and behavior of the extremities during rest, 
are of the greatest import. Respiration during rest is more instruc- 
tive than in a condition of unrest and wakefulness. The patient 
should be completely undressed for examination. This is done as a 
routine procedure even in cases of apparently mild illness. Any 
eruption on the skin is thus forced upon the attention of the 
physician. 

The Skin. — The condition of the skin is noted in a general way, 
the absence or presence of an eruption, general form of the body and 
its gross nutrition, the shape of the chest, contour of the abdomen and 
extremities as to their conformity, as well as the power in the 
muscles and their contour. The weight of an infant is of essential 
importance, especially where feeding is concerned. 

The Head. — The examination of the head should begin with ob- 
servation of its size, whether normal or abnormally small or large. 
The general shape of the head and condition of the bones are of 
importance in reference to the presence or absence of rachitis and 
areas of craniotabes. The manner in which the head is held is noted, 
as bearing on the presence of torticollis. In Pott's disease the head 
is held rigidly on the spine, and in older children supported with 
the hands. Some infants, for instance, amaurotic idiots and those 
suffering from birth-paralyses or diptheritic paralysis, are unable 
to hold the head upright. In forms of meningitis the head is re- 
tracted or held rigidly. The f ontanelles may be normal, tense, as in 
meningitis or hemorrhage, depressed, or abnormally prominent ; they 
may be closed prematurely, as in microcephalus, or open beyond the 
normal period. The presence of tumors underneath the scalp, such 



METHODS OF EXAMINATION. 6v 

as cephalhematoma, should be noted. The condition of the lymph- 
nodes posterior and anterior to the border of the sternomastoid muscle 
is of clinical importance. 

The Face. — The expression of the face in a condition of rest, and 
also when the infant or child cries, may enlighten us as to the presence 
or absence of paralyses. These may be localized, involving the 
muscles of one organ, such as the eye, or the whole side or both sides 
of the face may be affected. When the infant is asleep the mouth is 
normally closed and the infant breathes through the nose, the tongue 
being applied to the roof of the mouth. In so-called mouth-breathing 
the mouth remains open during sleep and the tongue is observed to 
lie at the floor of the buccal cavity. 

Respiratory Disorders. — In abnormal states, as adenoids, the breath- 
ing may be noisy; the cry may be peculiar, as described under 
retropharyngeal abscess; the lips may be cyanosed or the seat of 
rhagades or eruptions, such as herpes ; the symmetry of the face may 
be lost, as in parotiditis or adenitis, in which there is a swelling of one 
or both sides of the face. 

Cardiac Disease. — Cardiac disease in advanced stages gives a sad 
and anxious expression to the countenance, with exophthalmus or 
dilated pupils. 

Facial Paralysis. — Facial paralysis, either partial or complete, 
causes a characteristic facial expression. If the infant cries, or the 
child is made to smile, one side of the face remains immobile. Even 
in rest the angle of the mouth may be drawn toward the unaffected 
side of the face, as in tuberculous meningitis. 

Nuclear Palsy. — In nuclear palsy of the congenital variety de- 
scribed by Moebius and Schapringer (pleuroplegia) both sides of 
the face are immobile, and the face has a mask-like expression. There 
are no folds in the face either in the acts of laughing or crying. 

Basedow's Disease. — Basedow's Disease gives a peculiar expres- 
sion to the face, caused by the prominent eyeballs, which is pathog- 
nomonic of this disease. 

Hydrocephalus. — Hydrocephalus likewise lends a peculiar expres- 
sion to the face. The forehead is protuberant and overhanging. The 
eyeballs are forced downward, and the sclera are seen. The face 
proper is small as compared to that part of the head above the eves. 
This is due to the large size of the cranium. 

Rachitis. — Rachitis at times causes a characteristic facial expres- 
sion which is likely to be confounded with that due to hydrocephalus. 
In some rachitic infants the eyes are prominent and the sclera is 
quite apparent. The orbital plates of the frontal bone being thin, 
the weight of the brain depresses (lie eyeball to a very slight degree. 

Exhausting Diseases.- Exhausting diseases, such as diarrhoea, 



40 INFANCY AND CHILDHOOD. 

cause prominence of the eyes, giving a very characteristic expression 
— the so-called hydrencephaloid of older writers. 

Congenital Syphilis. — Congenital syphilis in some cases causes a 
deformity of the nose, which is present at birth. The result is a 
peculiar angular deformity of the normal nasal curve. Looked at 
sideways, the bony septum is depressed; the cartilaginous septum is 
still intact. An acute angle between the two results. This is similar 
to what is seen in destructive forms of syphilis later in life. The 
facial expression is characteristic of the disease. 

Palpebral Fissure. — The angle of the palpebral fissure is altered 
in conditions such as Mongolian idiocy. In this affection it is slightly 
oblique. In paralyses of the ocular muscles the palpebral fissure 
itself may be wider in one eye than in the other. In such cases, one 
pupil may be wider than the other (Horner's symptom). The pres- 
ence or absence of conjunctivitis, keratitis, nystagmus, paralyses of 
the orbital muscles, the condition of the pupils, are all points of im- 
portance in determining the status prsesens. In diseases of the brain 
or its coverings an ophthalmoscopic examination of the fundus oculi 
should be made. 

Sight. — In partial or total blindness, not only do the patients fail 
to notice objects placed in front of them, but there is in addition a 
vacant facial expression or stare. If the blindness is total, the finger 
will be suffered to approach the eye so as to touch the cornea. 

Some infants have a tendency to hold the head to one side. This 
may be due to defective vision or to weakness or spasm of the muscles 
of the neck. In cases of defective vision the head assumes a normal 
position if the eyes are not focused on any object. As soon, how- 
ever, as an effort is made to accommodate, the head is inclined so as 
to bring the planes of vision of the eyes in accord. 

Photophobia.- — Photophobia is an aversion to light, and is due to 
a spasm of the ocular sphincter in diseases of the conjunctiva or 
cornea (conjunctivitis, corneal ulcer). 

Nystagmus. — Xystagmus is a series of involuntary movements of 
the eyeball, due to inefficiency of certain muscles, and is met with in 
conditions of corneal opacity, congenital cataract, albinism, infantile 
amblyopia, spasms, nutation or head-nodcling, and in nervous states, 
such as amaurotic idiocy. In weakly rachitic infants nystagmus may 
be exhibited around a horizontal or vertical axis of the eyeball, or it 
may show itself in a rotary oscillation of the globe. It is made 
manifest in infants by causing them to focus some bright object, 
held slightly above and to one side of the head. 

The Chest. — Position of the Patient. — An infant should be so held 
for examination that the examiner and the patient may be at ease. 
Being undressed, with the thorax exposed, the infant is first held by 



METHODS OF EXAMINATION. 



41 



the attendant with the head looking over her shoulder, in which 
position the arms instinctively clasp her neck (Fig. 3). The patient 
so placed does not see the examiner. The spine should be straight, 
so that in percussing the sound is obtained on both sides under the 
same conditions. To examine the chest anteriorly, the infant is 
held looking forward, the anterior aspect of the thorax facing the 
examiner. If it is able to sit up, it may be examined in the sitting 
posture, both anteriorly and posteriorly. 

Fig. 3. 




Method of holding the infant for the examination of the posterior portion of the chest 

and lungs. 



With older children it is best to make an examination with the 
patient sitting upon a table or chair in a position convenient ro the 
examiner. If confined to bed, the child must be examined in bed. 
As a rule, however, it is preferable to have the patient taken oul of 
bed into the light. 

Infants and children sometimes try to grasp the instruments of the 
examinev; gentle suasion will reassure them, force is never necessary. 

Instruments Used.- Stethoscope. A stethoscope is absolutely es- 



42 



INFANCY AND CHILDHOOD. 



sential to the proper examination of the chest of an infant or child. 
This method is called mediate examination. We can by its means 
assure ourselves that the whole area of the chest has been carefully 
investigated. Examination by the ear — the immediate method — is 
uncertain. A small area of bronchopneumonia may easily escape 
detection in infants and children of tender age, in whom the axilla? 
and lateral regions of the chest should be carefully searched. Direct 
application of the ear to the chest is resented by infants and children, 
and is not a convenient procedure for the physician. With the 
stethoscope he can follow the movements of the body of a restless 
patient. 

The best form of stethoscope to employ is the binaural. The 
instrument devised by the author (Fig. 4) has given him the most 



Fig. 4. 




Author's form of stethoscope. (Archives Ped. } November, 1899.) 



uniform results. A larger stethoscope, such as that employed for 
examination of the adult chest, does not differentiate the variety of 
sounds as well as this small instrument, and may cause pain to a 
restless infant, inasmuch as the chest-piece must be held too rigidly 
and is likely to press painfully against the chest-wall. 

Tape-measure. — A steel tape-measure, marked off into inches and 
centimetres, is convenient for detecting inequalities in the size of the 
sides of the chest. 

Methods of Procedure. — Inspection. — We learn by inspection the 
shape of the chest and the character of the respiratory movements: 
also, the aspect of the cardiac area, the pulsation of the apex of the 
heart, its force and situation. 

Respiration in infants and children up to the age of ten years is 
of the abdominal or diaphragmatic type. The rapidity may be 
counted by noting the movements of the chest or by watching the 
rise and fall of the epigastric region in the recumbent patient. 

The Cardiac Area. — In some infants and children the cardiac 
area may be quite prominent in the absence of any cardiac dis- 
ease. In rachitic infants and children this part of the chest wall 
may conform to the shape of the heart. There remains even in the 



METHODS OF EXAMINATION. 43 

later childhood of rachitic patients a very slight rotundity or fulness 
of the precordial region. If the chest-wall is quite thin, the precor- 
dial region may normally present a wave of pulsation. All these 
signs may be exaggerated in disease of the heart. The apex-heat is 
normally distinguishable. Its force and area may be increased or 
diminished in disease. The apex-beat may be displaced upward 
and outward, or inward toward the median line (conditions of effu- 
sion in pericardium or pleura). 

Palpation.- — Palpation, by laying the palmar surface of the hands 
on the chest, is hardly to be attempted with young infants and 
children. In these subjects the chest is so small that this method 
cannot mark out areas of fremitus or absence of the same. To 
determine its presence, it is more satisfactory to use the internal 
border of the hand, generally the right. The hand is held horizon- 
tally, the internal border pressing firmly against the chest-wall. 
Thus the slightest variations in vibration of the chest-wall can be 
detected. We begin above at the upper border of the chest and 
pass downward, comparing both sides. If the infant or child cries, 
so much the better. If we wish to ascertain the presence of fremitus 
in a baby, we may even cause it to cry. An excusable procedure is to 
press gently the cheeks of the infant with the thumb and index finger 
in a teasing manner; the infant will resent this by crying. Older 
children may be asked to count or induced to talk. In infants and 
children fremitus is not so marked or useful a sign as in the adult. 
Normally, it diminishes in intensity toward the base of the lung. In 
some children it is detected in the lower part of the thorax only by 
careful examination. It is normally well marked along the axillary 
line; it is most marked along the mid-regions of the chest between 
the scapulae behind. Anything which separates the lung from the 
chest-wall will diminish or extinguish fremitus. Solidification of 
lung tissue will cause better conduction and increase it. 

Percussion. — It is not advantageous to use a pleximeter in ex- 
amining infants and children. The index finger of the left hand 
is laid horizontally on the chest with firm pressure. The skin or 
chest-wall and finger are thus made one medium. Percussion is 
performed by making a hammer of the middle finger of the right 
hand. The force used should come from the wrist ; the forearm 
should be immobile. The stroke is expended upon the middle 
phalanx of the finger on the chest-wall, and should bo of a tapping 
character, similar to that used in striking the keys of a typewriter; 
there should not be a pushing motion. The force should not be 
great. A force equal to that necessary in the examination of the 
adult chest would set in vibration all the neighboring ehest and 
abdominal organs and cavities, and would not bring out the delicate 



44 INFANCY AND CHILDHOOD. 

distinctions of sounds necessary to diagnosis. Moreover, to some 
rachitic infants and young children a forcible stroke is distinctly 
painful. 

The Abdomen. — The abdomen of an infant or child is best ex- 
amined Avith the patient lying on a bed or a table covered with a soft 
blanket. The mother's or nurse's knees are not so satisfactory a sur- 
face for this purpose. The patient should be completely undressed. 

Inspection. — Inspection should include the examination of the skin 
as to color, presence or absence of an eruption, oedema, and of the 
abdomen as abnormally rotund or relaxed. In the latter condition 
we may sometimes make out the coils of intestine. Peristalsis should 
be noted especially in cases of persistent vomiting, obstruction of the 
intestine, or stenosis of the pylorus. In diseases which exhaust the 
strength of the patient we distinguish between relaxed and retracted 
abdominal walls. A retracted abdominal wall may be tense and 
incurvated — the so-called boat-shaped abdomen ; this is seen in menin- 
gitis. In some rare forms of septic peritonitis the abdomen may be 
retracted. The pain of a colicky attack will cause the abdominal 
walls to be tense although not retracted. In intussusception the coils 
of intestine or even the intestinal tumor may be seen on the surface. 
Ascites distends the abdomen, and when marked the rotundity is 
characteristic, and the skin is tense and shining. 

Peritonitis. — Peritonitis causes tympanitic distention. In per- 
foration of the intestine in typhoid fever or appendicitis the tympa- 
nites is accompanied at an early stage, as in the adult, by disappear- 
ance of the liver dulness. This sign will aid us more if the liver 
dulness and flatness have been determined accurately in advance of 
any complications. 

Free Fluid. — The presence of free fluid of an inflammatory na- 
ture may be determined by percussing for dulness in the flanks with 
a change to tympanitic resonance in the same situation on a change 
of position as in the adult. 

Tumors. — Abdominal tumors give an uneven contour to the ab- 
domen. Such tumors are met in diseases of the spleen or kidney, 
enlargements of the liver, congenital renal cysts, ovarian tumors, or 
hydatid cysts. 

Palpation. — We palpate for pain, general or localized, and to 
determine the size and position of the abdominal organs ; for tumor 
whether of or behind the peritoneum, tumors of the liver, kidney, or 
spleen; enlarged glands behind the peritoneum in the neighborhood 
of the mesentery of the small intestine ; polypi in the lumen of the 
intestine ; tumors due to appendicitis or intussusception. 

In palpating, we follow a certain routine, and palpate in the 
region of the spleen, then over the liver, and finally in the right 
inguinal region (appendicitis). 



METHODS OF EXAMINATION. 45 

Ascites. — The signs are the same as in the adult. 

Tympanitis. — Tympanitis gives the same signs as in the adult. 
In newly born infants there is in rare cases a congenital weakness 
of the walls of the intestine. Any disturbance of the intestinal tract 
results in immense distention, which may be distressing to the patient. 
E"on-inflammatory is distinguished from inflammatory distention 
(peritonitis) by the absence of prostration or fever and the absence 
of free fluid in the abdominal cavity. There is another form of 
distention which precedes death in severe pneumonia or gastro- 
enteritis. Simple tympanitic distention is seen in rachitic children, 
in whom the lower part of the chest is narrowed and the abdomen 
uniformly protuberant ; in these children the distention is apparently 
increased by the forward curvature of the spine. Percussion gives 
a uniformly tympanitic note all over the abdominal area, except 
where fasces change the note into a dulness. There is no pain or 
only slight general tenderness. 

Pain. — Children may locate the pain felt in pneumonia, pleurisy, 
or pericarditis in the abdomen. The pain in these cases may be 
referred to the upper part of the abdomen. The patient may com- 
plain of pain radiating to the right inguinal region, and thus in lobar 
pneumonia of the lower portion of the right lung mislead the ex- 
aminer into a consideration of the existence of appendicitis. In 
diffuse peritonitis the pain is general, but in localized disease of the 
vermiform appendix the limitation of pain can be made out even in 
young subjects. If we suspect appendicitis, it is best to examine 
every part of the abdomen for pain before approaching the right 
inguinal region. 

In connection with pain and its significance, we may emphasize 
the fact that if the abdomen is relaxed (not retracted), showing the 
grooves due to the muscular parts of the abdomen — the bellies of 
the recti muscles, the incurvation of the abdomen just below the 
border of the ribs — we may assume the absence of tympanites. In 
such cases peritonitis is rarely present. Pain, which has no definite 
localization in an abdomen relaxed as above described, may be con- 
sidered as of no serious import. 

The condition of the abdomen in intussusception is described in 
the chapter treating of that subject. 

Polypoid tumors in the lumen of the ascending or descending 
colon may sometimes be distinctly felt in the relaxed abdomen to 
one side of the umbilicus. 

Floating kidney in children has been recently described by 
Comby. The methods of examination in forms oi kidney tumor or 
displacements of this organ are described in (he chapter devoted 
to those subjects. 



46 IXFAXCY AND CHILDHOOD. 

Rectal Exploration. — This is always carried out in the recumbent 
position. By rectal examination we may establish the presence of 
an abscess in the right inguinal region or of great swelling of the 
appendix in cases in which it is bound down by adhesions below 
the brim of the pelvis or of ischiorectal abscess. Rectal exploration 
is resorted to in all cases in which we are led to suspect the presence 
of an intussusception. In tuberculous peritonitis also, enlarged 
lymph-nodes may be felt through the walls of the rectum. Kidney 
and ovarian tumors can in some cases be felt through the rectum. 

It is not necessary to cause pain in the above procedure. On 
the contrary, rude examination only obscures the case. We should 
seek every opportunity to become familiar with the normal condi 
tions externally and per rectum, especially in the vicinity of the right 
inguinal region in order to be able to diagnose abnormal states. 

The Joints. — Affections of the joints are among the most frequent 
diseases of infancy and childhood. The method of examination of the 
joints should be familiar to every physician. If a mother states that 
her baby cries when it is bathed or diapered, we should examine the 
joints. In the newborn infant especially this holds true. If there is 
any limitation of motion, or should the extremities be limp, the joints 
should be inspected. In older children a sudden limp or intermittent 
obscure pain in a joint should receive attention at once. 

Position. — To examine the joints, the patient should be completely 
undressed, and placed on a table. The spontaneous movements of 
the limbs are first observed before any manipulation of them is 
attempted. We may thus observe that one limb is favored by the 
infant, limitation of motion may exist, or there may be a marked 
swelling of one joint. The shoulder, elbow, knee, ankle, and other 
joints are systematically examined. This can be done in quite a 
short time if we make it a routine of every physical examination. 
In examining a joint we should not forget that when inflamed, it is 
very painful if not gently handled, and that any rude procedure, 
in addition to causing pain, may injure the joint. 

The joint is inspected as to whether it is swollen, or has its normal 
form, or shows too plainly the prominences of the bones entering into 
its formation. Palpation will tell whether the temperature of the 
surrounding tissues is raised, whether there is fluid in the joint or 
whether the tissues about it are infiltrated. We also examine by mild 
pressure with the fingers the region of the junction of the epiphysis 
and diaphysis for tenderness. 

Motility. — Motility is tested by flexing, extending, rotating, ab- 
ducting, and adducting. During such an examination we also note 
muscular spasm. 

Joint-crepitus. — Joint-crepitus is a peculiar crackling, rubbing 



METHODS OF EXAMINATION. 47 

sensation found frequently in the joints of infants and children. It 
is detected by placing the palmar surface of the hand upon the joint 
and moving the extremity which enters into its formation. It has 
been found by the writer in children who complained of no definite 
joint-symptoms. It may, under these conditions, be present in many 
joints of the same patient. Some infants and children are " loose- 
jointed," that is, they possess a facility in causing subluxation of their 
joints and spontaneously reducing this subluxation with a snapping 
sound. Faint crepitus is found in children who have had an attack 
of rheumatism. 

Most Common Affections. — The most common affections to look for 
about the joints are simple luxations; syphilitic disease; osteomyelitis 
of a septic or infectious nature; scurvy of the joints or epiphyses in 
the vicinity of the joint ; rheumatism, simple acute or chronic, and 
gonorrhoeal ; tuberculous joints, especially the hip ; paralyses (deltoid) 
of muscles about a joint; deformities, as in congenital coxa vara. 

The Spine. — Anatomy.- — The spinal column of the newborn infant 
is practically devoid of natural fixed curves. Fehling found that 
there was an almost imperceptible curve backward (kyphosis) in the 
dorsal region and a slight lordosis in the lower lumbar region. The 
latter curve was more marked when the extremities of the infant were 
extended. The fixed cuves seen in the cervical dorsal and lumbar 
regions later in life begin to form in the first year. They are fully 
fixed by the seventh year. 

Method of Examination. — The purpose of examination is princi- 
pally to discover abnormal curvatures and to test the pliability of the 
vertebral column. In other words, we examine for rigidity due to 
disease (Pott's). The patient is undressed and caused to stand 
erect. The index finger is passed down the vertebral spinous proc- 
esses, and the lines of these processes are marked out. Any ab- 
normal curve is thus made apparent, Painful areas are detected by 
pressure or tapping along the spinous processes. If deformity is 
present, it is important to decide whether this is permanent and 
combined with muscular spasm (Pott's") or due to rachitis. For 
this purpose the patient is placed on the examining table face down- 
ward. The examiner grasps both lower extremities at the ankles 
(Fig. 5). The palmar surface of the left hand is laid firmly on 
the junction of the cervical and dorsal spine. The extremities are 
now raised and hyperextended with the right hand. If the spine 
is supple and normal, it will curve backward as the pelvis is raised 
toward the vertical. If there is deformity due to Pott's disease, 
this will persist, Deformity due to rachitis will disappear under 
this manipulation. In hip disease, if the left band is laid on the 
lumbar region and the above hyperextension gently carried out, first 



48 



INFANCY AND CHILDHOOD. 



flexing the legs back at a right angle and then lifting them vertically, 
a distinct spasm of the muscles is felt (psoas spasm) (Fig. 6). 
Spinal rigidity is also made apparent by causing the child to pick 
up some object from the floor. Under conditions of disease the 
patient will hold the spine rigid in picking up the object. The hips 

Fig. 5. 




tZSttyi*^ 



Method of testing mobility and pliability of the spine. 



and knees are bent, but not the spine. To test the rigidity at the out- 
set of a meningitis, the head is raised as the patient lies recumbent. 
In meningitis the rigidity is such that the whole trunk can be raised 
by placing the palm underneath the occiput and gently raising the 

head. 

Fig. 6. 




^ZJlti/itif: _— 



Method of testing for psoas spasm. 



METHODS OF EXAMINATION. 40 

Muscular Apparatus and Nervous System. — Form. — Atrophy. — 
Atrophy of muscle is seen in any disease which affects the trophic 
centres of muscle in the cord. Such diseases are poliomyelitis, and 
neuritis following traumatism, diphtheria, measles, or any infectious 
disease. Atrophy is seen in joint-affections, especially about the hip. 
In the latter case, not only disuse, but a true reflex trophic disturb- 
ance is the cause of the atrophy. 

Hypertrophy. — Hypertrophy of muscle is seen in cases of iso- 
lated congenital hypertrophy of one limb, and also in pseudohyper- 
trophic paralysis. In all cases of change of volume of a muscle we 
compare the affected limb with that of the opposite side if the disease 
is unilateral. The diseased limb is measured in its circumference and 
compared with the corresponding healthy limb. 

Reflexes. — Patellar Reflex. — We shall take up only that aspect of 
the subject which should concern the practitioner in his examination 
of infants and children. The minutiae of electrical muscle and nerve 
reactions may be gleaned from works treating of such matters in 
detail. 

The most common deep reflex is that of the patellar tendon. It 
is obtained by placing the infant in a recumbent position, supporting 
the thigh by placing the left hand beneath it, and raising it above 
the level of the body. When the muscles are relaxed, tap the patellar 
tendon sharply with the middle finger of the right hand. The 
procedure is similar to that employed in percussion of the chest. Both 
limbs are examined in the same manner. Children who can sit are 
placed on a table with their lower extremities dependent. When 
the attention of the patient is fixed upon some object the tendon is 
tapped sharply. A percussion-hammer is not necessary. 

In diseases of the gray matter and of the posterior columns of 
the cord with trophic disturbance of the nerves (poliomyelitis, neu- 
ritis, Landry's paralysis, diphtheritic paralysis) the patellar reflex is 
diminished or absent. 

In brain tumor and in affections of the lateral columns of the 
cord (multiple sclerosis, spastic disease) the reflex is increased. 

The reflex is unimpaired in cerebral palsy, Friedreich's ataxia. 
and in cases of idiocy. 

Babinskis Reflex. — Babinski's reflex is a plantar phenomenon 
found in some forms of meningitis (tuberculous), and in diseases in 
which there is irritation or involvement of the pyramidal tracts. On 
irritating the plantar surface of the foot with the tip of the index 
finger there is a vigorous hyperextension of the great toe with spread- 
ing of the adjacent toes. Morse has shown that this reflex cannot be 
relied upon in children under two years of age. I have had abundant 
opportunity to confirm this observation. As a differentia] diagnostic 

4 



50 INFANCY AND CHILDHOOD. 

sign, the Babinski reflex is of little value, although I have observed it 
to be present more frequently in the tuberculous forms of meningitis 
than in the pyogenic varieties. 

Kernig's Symptom. — Kernig's symptom is the flexion of the leg 
on the thigh when the thigh is flexed at right angles to the trunk, and 
is found in children suffering from any form of meningitis, and in 
diseases such as pneumonia or typhoid fever with cerebral symptoms 
or so-called meningism. The sign has the same characteristics as in 
the adult. In infants under one year the tendency to flex the leg on 
the thigh is normal. In these subjects, therefore, the presence or 
absence of this sign possesses no significance. 

Gait or Walk.- — The child is undressed, so that the feet and toes 
are exposed, and is caused to walk to and fro in front of the physician. 
The gait in disease may be ataxic, spastic, paretic, or wabbling. 

Ataxic Gait. — Ataxic gait is seen in children suffering from 
Friedreich's ataxia, or from tumor involving the motor centres for 
the lower extremities. The gait is uncertain; patients walk as if 
inebriated, with the feet wide apart. Incoordination of movement is 
characteristic of all these cases. We must in all cases distinguish 
between simple muscular weakness, as in pseudohypertrophic paraly- 
sis, and convalescence from acute disease, such as fevers, and a weak- 
ness combined with a palpable defect in the power of coordinate 
action. In cases of cerebral disease, as a rule, there is lack of coordi- 
nation elsewhere, as in the muscles of the upper extremities. In these 
cases the coordination is tested in older children by telling the 
patient to close the eyes, and directing him to touch the tip of the 
nose with the index finger of the right hand several times in succes- 
sion. In cases of ataxia there will be great uncertainty in carrying 
out this manoeuvre. In diphtheritic paralysis there may be combined 
with a real weakness, ataxia or incoordinate movement. If we 
remember that in these cases there is a neuritis, with consequent 
atrophy of muscle and loss of reflex, we shall not commit the error 
of overlooking the paralysis in our desire to account for the condi- 
tion present as a simple muscular weakness the result of the illness. 
In these cases there may also be paralyses of the trunk muscles, 
causing inability to assume the upright posture. In ataxia caused 
by cerebral tumor there is in certain cases a crossed hemiplegia 
(pons tumor), with foot-clonus and paralysis of ocular muscles, which 
aid in the diagnosis. 

Cerebellar Titubation. — In cerebellar tumor, which is the variety 
most common in children, there are at the outset, in most cases, 
disturbances of the gait or ataxia. The patients walk in an uncer- 
tain manner, generally staggering to one side. In severe forms of 
this disease the patients will fall to one side if not protected. The 



MANAGEMENT AND HYGIENE OF NORMAL INFANT. 51 

cases thus far recorded all show early involvement of the optic, 
auditory, and other cranial nerves, abducens paralysis, with symp- 
toms of vertigo. 

Spastic Walk. — This walk is so characteristic as not to be easily 
mistaken for anything else. It is found in all forms of spastic 
paraplegia, congenital or acquired. There is not only actual spasm, 
but also weakness of muscle. There are other phenomena of nervous 
disturbance, such as increased patellar reflex and foot-clonus. The 
patient seems to drag the legs in walking. Each extremity is brought 
rigidly forward, the toes scraping the ground. The muscles may or 
may not be well nourished. Electrical contractility may or may not 
be increased. The children may walk cross-legged (Gowers). At 
first there is inability to walk; later in childhood locomotion is pos- 
sible. In certain forms the spasm of the extremities is so great as to 
keep them in constant extension at the knee ; flexion in these cases 
can only be attained with great expenditure of force. 

In infants and children who cannot walk and are the subjects 
of spastic paraplegia the characteristic position of the lower extremi- 
ties may be made apparent by supporting the patient on the feet. 
In all of these cases, as soon as the toes touch the ground the reflex 
produces the characteristic extension of the limbs, with the toes or 
ball of the foot on the ground and the heel raised. 

In very young infants who are the subjects of amaurotic idiocy 
the spastic phenomena are sometimes very marked. In these cases 
there are other symptoms, such as amaurosis and inability to hold 
the head upright, the presence of the Tay-Kingdon spot in the 
fundus of the eye, to aid in the diagnosis. 

Limping Gait. — Joint-affections cause simply a limping gait; a 
study of the joint, as described elsewhere, will aid the diagnosis. 

Infantile Paralysis. — Infantile paralysis, or cerebral palsy, at the 
outset causes a characteristic dragging of the extremity if the paraly- 
sis is not complete. Infants in whom there is a complete loss of 
power in one or both lower extremities give a history as follows : The 
infant may have been able to walk or stand ; the attack suddenly de- 
prives it of the power of motion. There is a limp extremity on one 
or the other side, with rapid atrophy of muscle and loss of reflex. In 
cerebral palsy there is no atrophy and the tendon reflex is present. 

The methods of examining the mouth and special organs will be 
considered in the chapters devoted to them. 

MANAGEMENT AND HYGIENE OF THE NORMAL INFANT. 

Taking the Infant from the Mother at Birth. — As soon as the 
infant is born and pulsation in the cord lias ceased, the cord is tied 



5*2 INFANCY AND CHILDHOOD. 

and the physician places the newborn in the care of the nurse. The 
tying of the umbilical cord should be performed rapidly, and the 
nurse, for this purpose, should have at hand a piece of sterilized tape 
or broad * binding-silk and scissors which have been boiled in water 
and then carefully wrapped in a clean towel. It is not necessary to 
use silk which has been soaked in antiseptic solutions, such as car- 
bolic acid, for the infant is peculiarly susceptible to these drugs. I 
have seen an infant whose cord was tied with silk saturated with a 
very strong solution of carbolic acid who, within a few hours after 
birth, showed signs of the action of the drug. The sterilized tape and 
scissors should be in readiness for the physician, as searching for the 
tape or scissors causes an inexcusable delay. A warmed piece of soft 
blanket is wrapped about the infant at once. As is well known, the 
infant at birth cries lustily ; nature intends that it should be so at this 
time in order that the lungs may be filled with air. 

Umbilical Cord. — -Tying of the Cord. — The physician should tie 
the cord, as has been stated, with a piece of sterilized tape or broad 
binding-silk, about an inch or an inch and a half from the body, after 
the pulsation of the cord has ceased, unless some feature in connection 
with labor indicates a more rapid procedure. After the initial bath 
the cord is inspected to see that the first ligature is still intact. Ahl- 
feld, after having placed the primary ligature, reties the cord close 
to the abdominal wall, though this seems to be unnecessary. If the 
ligature is still in place and there is no hemorrhage, the stump of the 
cord and the surrounding tissues are washed with strong alcohol, and 
a sterilized dry gauze pad with inclosed absorbent cotton is folded 
over the umbilical stump. This is held in place with a clean body- 
binder. The first dressing is not removed until the stump of the cord 
has fallen off and the umbilicus has healed, unless there is some in- 
dication for its renewal, such as the soiling of the dressing by the 
urine of the infant (Ahlfeld). 

Another method of dressing the cord is to form a pad of absorb- 
ent gauze four or five layers thick, about three inches square, cutting 
a small opening in the centre. The stump of the cord is passed 
through this opening and the gauze folded over the stump. The 
dressing is secured with an ordinary body-binder. This dressing, 
also, is not disturbed unless it is soiled by the urine of the infant. 

Stump of the Cord. — The stump of the umbilical cord dries up 
and falls off from the sixth to the tenth day. It may fall off as 
early as the third or as late as the fourteenth day. In premature 
or weakly infants this process is delayed. Even in healthy infants a 
delay may occur which has no pathological significance. When the 
stump of the cord drops off there remains a flat, granulating surface, 
which cicatrizes, and after a time takes on the appearance of the 



MANAGEMENT AND HYGIENE OF NORMAL INFANT. 06 

neighboring skin. Occasionally, however, the site of the stump takes 
the "form of a small pea-like body, sometimes having a thin pedicle. 
This is made up of granulation tissue and has been called fungus of 
the umbilicus. It will be discussed elsewhere. Normally there 
should be no protrusion of the umbilicus, even when the baby cries. 

The drying or mummification of the stump of the umbilical cord 
is a purely physical process, and depends more or less on the dryness 
of the dressing on the stump of the cord. When the stump of the 
cord remains dry, but few bacteria are found in the tissues ; if, how- 
ever, as in very exceptional cases, moist gangrene of the stump takes 
place, staphylococci and streptococci in large numbers appear in the 
stump and the immediate vicinity. The stump of the cord is thrown 
off by a sort of reactionary inflammation at the point of juncture of 
the amnion sheath of the cord and the skin. A few hours after birth 
the capillary network in this vicinity is seen to become congested. 
The amnion first separates, then the arteries, and finally the vein, 
leaving a granulating base at the umbilicus. 

Bathing. — First Bath. — The question has been much debated as 
to whether an infant should be bathed immediately after birth or 
whether the body should be simply anointed with vaseline or olive oil, 
wiped off, and not bathed until the stump of the cord has fallen off 
Whatever objection there is to bathing premature infants, this cannot 
hold with infants at full term. The bath is cleansing. The lochial 
discharge of the mother if allowed to remain in contact with the skin 
is apt to decompose, and a source of infection is at once presented. 

The most convenient form of bath-tub for the infant, if it can be 
obtained, is that constructed of rubber sheeting. It obviates placing 
under the infant any blankets, as must be done in a bath-tub made 
of metal. These bath-tubs are constructed so as to have a certain con- 
venient height from the floor. They hold heat better than the metal 
bath-tub. 

The temperature of the room in which the newborn infant is 
bathed should be 70° to 72° F. The bath-tub should be situated, if 
possible, near an open fire, to insure warmth. 

At birth the infant is covered with a white substance, the vernix 
caseosa, which must be carefully removed, and to this end the body 
is anointed with vaseline or olive oil, the latter being preferable to 
vaseline, which may irritate the skin. When the infant is anointed 
it should be exposed part by part only, in order to guard against rapid 
reduction of body-temperature, and care should be taken not to dis- 
place the ligature or roughly handle the stump of the cord, lest 
hemorrhage result. The first bath is, therefore, a scientific function; 
it cleanses and protects the infant from present and future auto- 
infection. The water in which the infant is bathed should be boiled. 



54 INFANCY AND CHILDHOOD. 

in order to destroy any extraneous source of infection, for, as will be 
seen later, the bath-water has been the cause of epidemics among the 
newborn, especially in hospital service. In private practice this 
danger does not obtain to the same extent as in institutions. 

The infant should be bathed rapidly, and at the same time in a 
painstaking and gentle manner. The water of the bath should be 
100° F., and some additional warm water should be at hand in order 
that the temperature of the bath water may be maintained at this 
point. The infant is placed in the bath, rapidly washed with glycerin 
soap, and lifted out and placed in a warm blanket. The depth of the 
water in the tub should be just enough to cover the body. The head 
is supported above the water by the disengaged hand of the nurse. 
The infant cannot slip out of the arms of the nurse. While in the 
bath the infant is constantly but gently rubbed, and when taken from 
the bath should not be blue or in the least chilled. Drying the infant 
is best performed on the knees of the nurse, part by part, so as not to 
expose the infant's whole body at one time. The cord is dressed as 
above described and the binder applied. All clothing, including the 
binder of the newborn infant, should be made of soft flannel or pure 
wool. 

Daily Bath. — There has been some discussion as to whether an 
infant should be bathed daily, after the first bath, before the separa- 
tion or falling off of the stump of the umbilical cord. It has been 
demonstrated that infants who are not bathed in the first week lose 
less in weight than those who are bathed. It is best, therefore, in 
order to avoid infection of the umbilical wound, to favor mummifica- 
tion of the cord, as well as to conserve the weight of the infant, 
not to give a full bath, after the first bath detailed above, until the 
umbilical wound has healed and the stump of the cord has separated. 
When this has taken place the infant is bathed daily ; up to that time 
it is washed twice daily, with a view to cleanliness. If the dressing 
on the umbilical stump has become soiled with urine, or otherwise, 
it is changed; but unless this indication exists the first dressing is 
left undisturbed. 

The best time for the bath is in the forenoon, one hour after 
nursing. The temperature of the water of the infant's bath should 
not be below 99° or 100° F. during the first ten days; 95° F. dur- 
ing the first month of infancy; and 90° F. after the sixth month. 
It has been proposed — on grounds which are somewhat obscure and 
not founded on physiological facts — to harden the infant by means 
of a gradual reduction of the temperature of the bath-water until, 
even with an infant below one year, the bath-water is quite cool. 
Such a procedure does not harden the infant ; on the contrary, it has 
been shown that it is directly detrimental to his growth and well- 



MANAGEMENT AND HYGIENE OF NORMAL INFANT. 55 

being. Delicate infants, even those born at full term, may by such 
a process of hardening contract a bronchitis, or even some more 
dangerous affection of the lung. 

The details of the daily bath are much the same as those de- 
scribed with the newborn infant. The use of a sponge in bathing 
is not cleanly or desirable. A soft piece of linen or muslin or so- 
called washcloth is much to be preferred, as it can be easily cleansed 
and boiled. After the bath the infant is taken from the water and 
placed in a soft, warm blanket or bath robe, carefully dried and 
powdered. Powder is applied to the axillae, groins, buttocks — where 
surfaces come in contact. The general surface of the body is not 
powdered unless some indication exists. 

Premature Infants, and Infants who are Under Weight.- — Infants 
born prematurely or those who weigh six pounds or less, even though 
born at full time, should not be bathed as above described, but are 
best washed part by part with warm water once a day until the 
weight has reached the normal limits. These puny infants are par- 
ticularly susceptible to reduction of temperature. In fact, the rectal 
temperature in such infants is always low, and any bath, even a 
warm one, will reduce the temperature still more and may result in 
serious chilling of the body. 

Hardening. — It will be seen from what I have said that I do not 
believe in the so-called hardening process as applied to children. I 
have seen children, whose mothers took a pride in bathing them with 
cold water, who remained pale, stunted in growth, nervous, even with 
a flabby musculature, notwithstanding a daily regimen of cold water 
which was intended to have a tonic effect, both on the general nervous 
system and physical development of the child. I have rarely found, 
at least in this climate, that' any other temperature for bathing was 
indicated but that which has been mentioned above. A very excel- 
lent guide as to the proper effect of any form of bathing on an infant 
is the so-called reaction in and immediately after the infant is taken 
out of the bath. In the bath and after bathing the infant should be 
warm on the surface and present a ruddy appearance. If during or 
after a bath the infant is cyanosed and the surface of the body is cool, 
wo will conclude that the bath, at whatever temperature it is given, is 
not adapted to the infant. 

Eyes. — In a maternity service, where numbers of women are de- 
livered and there is danger of one infant being infected by anorher, 
it is customary to instil into each eye at birth a drop of a 2 per 
cent, solution of nitrate of silver. This is done as a prophylactic 
measure against gonorrhoea] ophthalmia, a disease which lias been 
proved to be a great etiological factor in the causation of blindness. 
In private practice, however, this is scarcely necessary (see Oph- 



56 INFANCY AND CHILDHOOD. 

thalmia Neonatorum), especially if we are acquainted with the con- 
dition of the mother and no vaginal discharge has been present pre- 
vious to labor. If, however, there has been a vaginal discharge 
before labor, it is well either to apply the Crede method and instil 
a drop of a 2 per cent, solution of nitrate of silver into the eye, or to 
carry out the prophylactic measure of Kaltenbach, described in the 
section on Blennorrhoeal Ophthalmia. 

The eyes during infancy need no attention other than that cus- 
tomary in the adult — cleanliness. Any slight discharge from the 
eye indicates a conjunctivitis. The nearer this conjunctivitis occurs 
to birth, the more we should be on guard for detection of a gonor- 
rheal process. It is always wise, therefore, as soon as any secre- 
tion of pus is detected in the eyes of the newborn infant, to examine 
this pus for microorganisms of a specific nature. Any swelling of 
the conjunctiva or the lids should put us on our guard against gon- 
orrheal infection. 

Method of Taking the Body-temperature of the Infant. — The 
temperature of infants and children is always taken in the rec- 
tum ; but if the child is above five years of age we may, under certain 
conditions, take an axillary temperature. Some children are terri- 
fied at the sight of a thermometer ; others have an innate mod- 
esty, which it is the duty of the physician to respect, and which 
precludes the taking of a rectal temperature. If the indication is 
not pressing, therefore, an axillary temperature may be taken in 
older children in the same manner as in the adult. 

It is well in dealing with children to teach the parents how to 
use the thermometer. In this way each child may have its own 
thermometer, whether it is used in the rectum, the axilla, or the 
mouth. This is not only convenient for the physician, but is entirely 
proper, especially as applied to children, for thermometers cannot be 
thoroughly disinfected, and it is certainly objectionable for a phy- 
sician to go from one little patient to another, introducing the same 
thermometer into the rectum. 

In introducing the thermometer into the rectum, the infant or 
child should be laid on the side. The bulb of the thermometer 
is anointed with vaseline or olive oil, the buttocks are gently sep- 
arated with the fingers of the left hand, and with the right hand 
the bulb of the thermometer is carefully insinuated into the rectum. 
The infant or child is continued on the side for three minutes. Some 
thermometers register the temperature in less time. The thermometer 
is then removed, and after reading the register the physician should 
carefully cleanse the thermometer, before proceeding further, with a 
piece of cotton first, then with a fresh piece of cotton moistened with 
ether and then alcohol, and finally with a 1 : 2000 solution of cor- 



MANAGEMENT AND HYGIENE OF NOEMAL INFANT. o7 

rosive sublimate or a 0.5 per cent, solution of formalin. In private 
practice this paraphernalia is not always at hand, and the physician 
can see at once the utility of teaching the parents to have a thermom- 
eter in the house for the use of the child rather than that he should 
imperfectly cleanse his own thermometer and use it on another pa- 
tient. In children's hospitals this question of individual thermom- 
eters is of great importance, and no children's service can be con- 
ducted without danger of infections arising unless each patient has 
his or her own thermometer. 

Temperatures should be taken in mild cases of illness and in 
convalescence three times daily; in protracted and serious illness, 
such as pneumonia or typhoid fever, every three hours throughout 
the twenty-four. 

Diapers. — The diaper should be made of an absorbent material, 
such as well-washed soft muslin or linen, and should be about two 
yards square. It is first folded in the middle, then in three-cornered 
fashion, refolded, and thus applied to the infant. A diaper should 
not be covered with a rubber protection except during travel, inas- 
much as under these conditions the diaper becomes, if moistened, a 
species of poultice and intertrigo results, as well as eczematous erup- 
tions of the buttocks. Diapers should be applied warm and dry. A 
moist diaper will sooner or later cause a skin eruption. A diaper 
moistened with urine should not be dried and used again on the in- 
fant, for by this method the salts of the urine are crystallized in the 
meshes of the diaper fabric and will irritate the skin. Diapers when 
soiled should be placed in a covered utensil sold in the shops for this 
purpose. Before washing the diaper the excess of faeces should be 
removed. Diapers should be boiled in plain water, as soda in the 
water may irritate the buttocks, and should be washed by hand, not 
with the mandril, otherwise the faeces and discharges cannot be 
removed thoroughly. 

After a movement the child is dried gently with a piece of soft 
linen, sponges not being used, carefully powdered, and a new diaper 
applied. Diapers, if soiled, should not be put into a disinfecting 
solution. On the contrary, there is a positive objection to this, as 
diapers permeated with drugs may cause irritation of the skin of the 
buttocks. After changing the diapers, the nurse's hands and finger- 
nails should be cleansed with brush and file. This toilet o( the 
hands and finger-nails is very important, even with breast-fed in- 
fants, since the neglect of this function will result in a contamina- 
tion of the breast nipple or food with fsecal bacteria. Even the 
infant's own faeces may cause serious intestinal disturbance if rein- 
troduced in the above manner into the stomach and intestine. 

Care of the Genitalia.— The care of the genitalia in male and 



58 INFANCY AND CHILDHOOD. 

female infants is quite important, and it is surprising to see how 
such a simple matter is neglected by the mother and nurse. In 
female infants and children during the bath the labia should be 
washed, gently separated, and the parts beneath laved with water. 
After the bath these parts should be carefully dried, but not powdered. 
It is a very common practice to powder the parts beneath the labia 
majora in female infants. This custom causes considerable irritation 
around the introitus vaginas, as a result of the powders settling on 
the parts. If these parts are not powdered, but simply dried after 
the bath, they will remain in a normal condition, and an accumulation 
of smegma will be avoided. 

In male infants the prepuce should be retracted daily and the 
parts bathed with ordinary water. In this way accumulation of 
smegma, and balanitis will be prevented. It is not necessary to use 
medicated solutions, such as boric acid, for this purpose. In boys 
the scrotum, buttocks, and adjacent parts should be powdered. 

Play; Fondling. — It must not be forgotten that the average in- 
fant's stomach is easily upset, and that any kind of pressure on 
the abdomen is often a very effective way of emptying the stomach. 
After feeding, therefore, the infant should lie quietly in its crib and 
not be handled or fondled. Unless this rule is followed, vomiting 
after nursing will quite frequently occur. 

It should be remembered that too much play is apt to tire an 
infant as much as it would an adult. Infants who are played with 
and fondled to excess are tired, restless, irritable, and sometimes do 
not sleep. There is no rule to be applied, but moderation is to be 
followed in these things as in all others concerning the infant's 
pleasure. Children should not be allowed too much intercourse with 
adults, as this is also apt to have a deleterious effect. Children should 
play with children. Adults should limit their play and contact with 
children as much as possible. 

Sleep. — An infant in perfect health spends most of the time in 
sleep when it is not nursing. Unless its attention is engaged by 
others, it will not. play in the early months of infancy. After 
nursing, an infant falls asleep, generally on the breast. Therefore, 
if an infant cries or is restless after nursing, there is something at 
fault. Older children should sleep in the afternoon for one hour, 
after the midday meal. This should be especially insisted upon 
with children who have a nervous temperament. If such children 
do not attain an early habit of sleep in the afternoon they will be 
restless at night, and finally develop symptoms of neurasthenia. 

Bed. — The best bed for the newborn infant is one in the form of a 
bassinet. The infant certainly should not sleep in the bed with the 



MANAGEMENT AND HYGIENE OF NORMAL INFANT. 59 

mother or nurse, for, aside from the danger of so-called overlying, 
the infant is liable to become infected with the discharges of the 
mother; and in a breast-fed infant there is always a temptation to 
give the breast to the child at night whenever it is restless. Bad 
habits therefore result. Aside from this, an infant will be restless 
unless trained to sleep in its own bed. 

The mattress of the bed should consist of a hair cushion pro- 
tected by a rubber draw-sheet. Over this is placed a bed-pad, and 
over this the bed-sheet. After the fourth month an infant may be 
placed in a crib. For restless children cribs are made with high 
sides, so that they may not fall out. Kocking bassinets or cribs 
are undesirable. An infant accustomed to a rocking-crib or cradle 
will not fall asleep unless rocked, and the mother or nurse becomes 
a slave to the crib. If a baby' in early infancy cries without any 
apparent cause just as it is placed in the crib from the mother's or 
nurse's arms, it is best not to take it up immediately, for, unless 
this habit is broken in early infancy, an infant will refuse to be 
pacified unless taken up several times in the twenty-four hours. 

The physician may be consulted concerning the pillow for the 
infant, as to whether it should be made of hair or down-feathers. It 
is well for the young practitioner to know that a pillow made of 
the finest curled hair is really more comfortable than a down-pillow. 
When placed under the infant's head, the pillow should reach well 
beneath the shoulders, so that the head and shoulders are supported 
together. The custom of not using the pillow for the infant allows 
the head to come in direct contact with the mattress, a very uncom- 
fortable position, and one which inevitably results with careless 
mothers or nurses in a slight erosion at the back of the head, over the 
occiput. 

So-called pacifiers made of rubber or muslin should never be 
used in the nursery. They are undesirable and unnecessary, and 
if not used will not be in demand. 

Nursery. — The temperature of the room in which the infant 
passes its days should be carefully maintained at from 68° to 70° F. 
Variations in the temperature of the room not only chill the infant. 
but interfere with its growth and nutrition. Drafts are reprehen- 
sible. The air of the room should have no odor, and we should 
ventilate indirectly from another room which is warmed. Incense 
should never be used to cover up an odor. The nursery should be 
well lighted, as well as capable of ventilation. An open fireplace 
aids the ventilation considerably, ami in dam]) weather dries ami 
warms the atmosphere as wel] as ventilates the room. 

The floor of the nursery should be made o( hard wood or painted 
and covered with rugs. Carpels are not hygienic They must bo 



60 INFANCY AND CHILDHOOD. 

swept in situ; whereas rugs can be taken out, dusted, and aired. 
The crib should be protected from the open window by means of a 
screen. During infancy, up to the twelfth month, the temperature 
of the nursery, both day and night, should be kept at the same 
point. There is no reason why the temperature should be lower at 
night than during the day, as is customary in the sleeping-room of 
the adult. When the infant is in the open air, the nursery should 
be thoroughly ventilated for at least an hour a day. With premature 
children, however, we must be more careful and keep the temperature 
at a slightly higher point than the above. Or, if we have the room 
at 70° F., such children should be aided in maintaining the body- 
warmth by means of warm bottles placed underneath the blankets 
in the crib, but not necessarily close to the body. 

Open Air. — The infant may be taken into the open air three weeks 
after birth in the summer season and four weeks after during the 
winter, early spring, and fall. I have consistently advised that four 
weeks after birth, if the weather is not too cold, the newborn 
infant may be allowed an outdoor airing. I have seen no bad results 
follow from this advice. If the weather is exceedingly cold, com- 
mon sense would dictate that an infant should be kept indoors. A 
daily open-air exposure is always allowable in good weather, provided 
the infant be warmly clad, especially in the winter time, so as to run 
no danger of chilling. If an infant shows a tendency to be easily 
chilled when taken into the open, warm bottles should be placed under- 
neath the covers of the baby carriage. 

Infants should be protected from the direct rays of the sun, 
inasmuch as they burn and tan very readily. Tanning of the skin, 
or sunburn, is not necessary to the health of the infant. A physician 
will frequently be asked whether sleeping in the open air is injurious 
to the infant. It certainly is not, provided the infant is well pro- 
tected in the manner described above. Some infants fall asleep 
immediately on coming into the open. We could scarcely keep such 
infants awake, and nature simply indicates to us in this way that 
the open air is a tonic to the general nervous system. In large 
cities, both in summer and winter, the face should be protected 
by a veil when the infants are taken into the open. In the country 
this is especially necessary if mosquitoes and flies are in the vicinity. 
Children who are running about should not wear short stockings if 
the locality is infested with mosquitoes or insects. There is nothing 
particularly hygienic in the custom of wearing short stockings, and 
it exposes the children to the danger of infection, not only by 
mosquitoes (malaria), but by dangerous insects, such as spiders. 

Clothing. — The clothing of the infant should consist of a chemise 
of wool next the skin. Over this there should be a loose garment, 



MANAGEMENT AND HYGIENE OF NORMAL INFANT. 61 

either wool or flannel, reaching from the shoulder to below the feet, 
and sufficiently long to allow it to be folded upward. Garments 
should not restrict the chest in the old-fashioned way. The chemise 
should be made of gauze weight in summer and slightly heavier in 
the winter. Some infants cannot tolerate the contact of wool with 
the skin, because it causes an eruption of sudamina; in such cases it 
is well to place between the skin and the woolen garment a fine-linen 
chemise. 

Body-binder. — It is customary to provide the newborn infant with 
a body-binder made of soft, white, thin Shaker flannel, five inches 
wide and sufficiently long to pass two or three times around the body. 
It should be secured with strings, and not with pins, nor should it be 
sewed on the body. It is useful at first in retaining the dressing of 
the cord in place, and later on in supporting the umbilicus during 
straining or crying. The binder is discarded when the infant first 
makes attempts to stand. This usually occurs at the seventh month. 
The binder then loses its utility, inasmuch as the umbilical opening 
is naturally closed and supported by the muscular action of the recti 
muscles. It is customary, however, to substitute for the binder, when 
it is discarded, a so-called knitted flannel band, sold in the shops for 
this purpose. 

Skin. — The precautions which should be observed in drying the 
skin after the bath have already been mentioned. Dusting-powders 
that contain perfume should be avoided. Dusting-powder is applied 
with a puff of absorbent cotton in preference to a powder-puff. This 
absorbent cotton can be thrown away and a new pledget used at each 
dressing. To prevent caking, any excess of powder should be removed. 

If the skin is subject to sudamina in the summer, a handful of 
bran is added to the water, or, what is preferable, the bran is put 
into a gauze bag, moistened and expressed in the water of the bath 
until the water becomes turbid. Salt water irritates the skin of 
these infants and should not be used. 

Mouth. — It was formerly customary to wash the mouth of the 
infant thoroughly either after each feeding in bottle-fed infants, or 
two or three times daily in breast-fed infants. There is really no 
scientific indication for doing this if the rubber nursing nipples and 
the bottles used for artificially fed infants are kept scrupulously 
clean; and the mother's or nurse's breast nipple with the breast-fed 
infant be cleansed with a solution of boric acid before and after each 
nursing. Sprue or stomatitis will thus be avoided. Before the 
eruption of the teeth, the natural secretions of the mouth are quite 
sufficient to keep the mouth clean. 

The nurse should not introduce the finger into the mouth of the 
infant, either to cleanse it or otherwise, under ordinary circum- 



62 INFANCY AND CHILDHOOD. 

stances. I have seen stomatitis, both simple and gonorrhoea^ more 
commonly Bednar's aphthae, caused by the introduction of the finger 
into the mouth for the purpose of cleansing the same. 

After the teeth have appeared they may be kept clean by washing 
once a day with cotton moistened with boric acid solution. The best 
time is in the morning, after the bath; the mouth of the infant is 
carefully washed with a piece of absorbent cotton wrapped around a 
toothpick and moistened with boric acid solution. ISTo force should 
be used, and no hard pressure exerted against the roof of the mouth 
especially, as in this way ulceration may result. 

In order to avoid the introduction of sprue into the mouth, the 
bottle nipples should be boiled once a day for ten minutes in a soda 
solution, and cleansed carefully with hot water after each nursing. 
In the intervals of nursing the rubber nipples are best kept either' in 
a glass-covered jar or in a piece of absorbent gauze. It is well not to 
keep them in a solution of boric acid, as this is apt to become 
contaminated. 

It has been maintained by some that washing the mouth of the 
infant nursing at the breast is prophylactic against infection of the 
breast by bacteria of the infant's mouth. Aside from the fact that 
the bacteria which exist in the mouth of the newborn and young 
infant, before the eruption of teeth, are not pathogenic, no one has 
proved that they are capable of causing breast abscess. Epstein 
has shown conclusively that washing the mouth of infants is pro- 
ductive of infectious ulcerations of the mucous membrane of the 
buccal cavity, as well as the means by which extraneous infections, 
such as gonorrhoea and sprue are engrafted on the mucous membrane. 

In the newborn the production of buccal ulcerations as a result 
of a too diligent toilet of the mouth is not without great danger. 
It has been long acknowledged that bacteria may gain access to the 
circulation through these ulcerations and thus cause general sepsis. 

THE ADMINISTRATION OF DRUGS AND OTHER METHODS OF 

THERAPY. 

Medicinal Treatment. — Children should receive drugs in an 
agreeable form, although some may take nauseous drugs with ap- 
parent indifference. Bulky mixtures or drugs which are apt to upset 
the stomach should not be prescribed. The author has seen a severe 
enterocolitis set up by a cough mixture containing antimony. Drugs 
should not be administered in pill form to infants or children. Tab- 
lets are a ready means of administering certain drugs. They can be 
crushed and given in a teaspoonful of some indifferent fluid. Powders 
are also easily taken. They are put in a spoon, some fluid added to 



THE ADMINISTRATION OF DBUGS. 63 

form a mixture, which is then administered. Quinine is given either 
in syrup of yerba santa or in chocolate powder and water; or the 
child is given a piece of chocolate to eat, and the quinine is then ad- 
ministered. A child should never be forced to take a medicine. 
Much harm is done in this way. 

Certain drugs, such as opium in the form of the simple tincture 
or morphine, should be given with great caution to children under the 
age of two years. Atropine, of late advocated in cholera infantum, 
should be given cautiously to infants and young children. They bear 
this drug badly. Jaborandi is badly borne, as is also apomorphine. 
Camphor is a very good cardiac stimulant. It is useful in collapse, 
but must be given cautiously in cases in which there is diarrhoea. In 
the latter disease the camphor is apt to irritate the stomach and gut. 
The coal-tar series, such as antipyrin, antifebrin, and phenacetin, 
are powerful depressants. In those cases of fever in which it is not 
possible to give baths to lower the temperature we are sometimes 
forced to administer these drugs. It is then well to combine them 
with small doses of caffeine. 

If a child or an infant refuses to take a drug, it may be put 
in a teaspoon, the spoon held horizontally to the lips, and when the 
mouth is opened the spoon carried far back into the mouth and 
tilted. The spoon is held in the mouth until the act of swallowing, 
which must inevitably take place, is completed; the spoon is then 
withdrawn. If this manoeuvre is thus carried out, the fluid will not 
be rejected. Holding the nostril closed, and thus forcing the child to 
open the mouth, is bad practice. Patience and suasion can accom- 
plish as much in most cases. 

Digitalis is not given continuously, but is administered for two 
or three days, and when the pulse begins to show signs of lessened 
frequency its administration is suspended. Alcohol is well borne by 
children. I do not hesitate to. administer it in cases of nephritis if 
the heart is weak. In the gastro-enteritis of nurslings the stomach 
is intolerant of alcohol. It should not be given except in very severe 
cases accompanied by great prostration, as the vomiting is apt to 
be aggravated. 

Antipyretics. — Much has been written concerning antipyresis and 
antipyretics in the treatment of the diseases of infancy and child- 
hood. The young practitioner can feel assured that high tempera- 
tures are well borne by infants and children. A temperature of 
106.5° F. (41.3° C.) in an adult, although of short duration, would 
cause great alarm, and rightly so. On the other hand, such a tem- 
perature in an infant or child does not necessarily threaten life, nor 
is it incompatible with recovery. A convulsion is in some children 
the direct result of a rise of temperature. Such a convulsion will not 



64 INFANCY AND CHILDHOOD. 

necessarily lead to others nor to epilepsy. The heart and kidneys 
bear long-continued high temperature well in comparison with those 
of the adult. The most trivial causes will cause a rise of a degree 
or two in the temperature of an infant or a child. Taking all these 
idiosyncrasies into consideration, it may easily be understood by 
the student and practitioner why it is essential that methods of 
therapy should be modified before they can be applied to infants 
and children. A reduction of temperature from 104° to 102° F., 
even if it can be accomplished by a coal-tar derivative, does not 
cure the patient. Some diseases, such as measles, scarlet fever, 
pneumonia, and a number of others, run a course of high and low 
temperatures extending over a certain space of time. If an infant 
or child is attacked with convulsions following every acute rise of 
temperature, the parents should be warned of this fact. In these 
cases, as soon as a rise of temperature is noted, it should be com- 
bated by every means in our power. Reduction of temperature in 
such children at the outset of a disease is of the highest utility. 
It saves the nervous system from the shock of a convulsion. Hydro- 
therapy is, in such cases, the safest and most satisfactory antipyretic 
measure at our disposal. 

Dosage. — The dosage of drugs for infants and children has re- 
ceived much attention. In practice we judge more by the action of a 
remedy than the quantity administered. The initial dose should be 
small. Infants under a year receive %oth of the adult dose, and at the 
age of one year %oth of the adult dose is safe. At the fifth year %th, 
and at the tenth year % the adult dose is the rule. These figures are 
not absolute. Nitroglycerin if given in doses of less than %5oth of 
a grain has scarcely any effect on children five years of age. On the 
other hand, strychnine may be safely given in quantities of %5oth of 
a grain to infants, and %soth of a grain to children two to three years 
of age. It will be seen that if the hard-and-fast rule of division of 
doses according to age were followed, these drugs would necessarily 
be given in much smaller dose, and their action would be correspond- 
ingly inefficient. 

Hypodermic Administration. — Hypodermic administration of drugs 
to infants and children presents nothing peculiar, as compared with 
the same method applied to adults. 

Hydrotherapy. — The practice of hydrotherapy as applied to the 
adult must be somewhat modified before it can be carried out with the 
infant or the child. The reason for this is that the infant or child 
does not react so readily and cannot bear sudden changes of tempera- 
ture so well as the adult. 

The Sponge Bath. — A rubber sheet is placed on the crib, and over 
this one layer of a small blanket; the patient is then placed nude 



THE ADMINISTRATION OF DRUGS. 65 

on this blanket and covered with another blanket. There is thus no 
undue exposure. A small basin of water at 80° to 85° F., with a 
dash of alcohol, is now brought alongside of the crib. With a small 
sponge or piece of soft folded linen the parts of the patient are 
sponged; first one arm, then the other, then the trunk, and finally 
the lower extremities. As each part is exposed, the rest of the body 
is kept covered. This procedure is repeated until the body has been 
sponged for five or ten minutes. This method of hydrotherapy is 
especially suitable in acute rises of temperature of short duration 
and in mild cases of continued fever in which the temperature does 
not rise high. 

Cold Chest Compress. — Three layers of linen are cut so that they 
will envelop the trunk from the clavicles to the umbilicus. The gen- 
eral shape should be that of a shirt deprived of arms and open at 
the sides. On the outside of this linen compress there should be a 
compress of Shaker flannel cut in a similar manner. The compress 
of linen is moistened with water at 80° to 85° F. With robust 
children the water may be 70° F. The compress is wrung out and 
applied so that the neck, shoulders, and chest are covered as with a 
shirt. The flannel is now applied to the outside. The compress is 
moistened every hour with water at 70° to 85° F. and re-covered with 
the flannel. 

Cold Pack. — The cold pack is not so useful in the treatment of the 
febrile conditions of childhood. The method is similar to that fol- 
lowed with the adult, with the exception that the sheet is moistened 
with water at 80° to 85° F. In other cases the patient, after being 
wrapped in such a sheet, is rubbed by the attendant with ice on the 
outside of the sheet. 

The Full Bath. — The full bath, as advocated by Brand, is seldom 
carried out in the treatment of children. Children struggle against 
the bath, and if the temperature is too low, they become so depressed 
that it is difficult to rouse them. I therefore place children with 
typhoid fever, pneumonia, or scarlet fever in a bath at 100° to 105° 
F., and lower the temperature to 80° or 85° F., applying friction to 
the body constantly. After five or ten minutes the patients are taken 
out of the bath and rubbed dry. Warm-water bottles are applied To 
the hands and feet. 

In conditions of delirium and coma with a high temperature, in 
which (he heart is weak, 1 have given baths at a temperature of 
105° to 108° F. The eases in which these baths are indicated are 
those 4 in which any application of cold water causes cyanosis and 
collapse. I have seen infants suffering from bronchopneumonia, 
with high temperatures, in a condition resembling a rigor after a 



66 IX FANCY AND CHILDHOOD. 

bath at 85° F. With these infants the warm bath acts as a cardiac 
stimulant and is a sedative to the nervous system. 

Hypodermoclysis. — Hypodermoclysis is the introduction into the 
subcutaneous tissue of either a 0.6 percent, salt solution or the normal 
salt solution of Cantani (sodium chloride, 4 parts; sodium carbo- 
nate, 3 parts; water, 1000 parts). It is indicated in infants suffer- 
ing from cholera infantum and in other exhausting states. Monti, 
who was the first to apply this mode of therapy to the infant, injects 
100 to 200 c.c. at a time. Epstein showed that smaller quantities — 
10 to 40 c.c. — are more beneficial and more quickly absorbed. Ex- 
perience teaches that large quantities of fluid injected subcutaneously 
cause extensive blood extravasations in exhausted infants and much 
subsequent pain. The solutions used should be freshly prepared and 
sterilized. TVelch has reported cases of infection with Bacillus 
aerogenes capsulatus following hypodermoclysis. I have had one 
case, although every precaution was taken to avoid infection. 

A large antitoxin syringe, holding 30 c.c, is used. It should be 
carefully sterilized. Or a fountain syringe may be employed, and 
the solution introduced through a needle attached to the tubing of the 
syringe. 

From 20 to 30 c.c. of the solution is injected two or three times 
daily into the subcutaneous tissue of the lumbar region or abdomen. 
Monti injects into the subcutaneous tissue of the abdomen. Mas- 
sage should not be performed after injection, as it is very painful 
and causes hemorrhages. The puncture wound is covered with a 
piece of sterile gauze. The main point is to inject small quantities 
of the solution at intervals of from four to six hours, and watch the 
effect. The action is that of a stimulant to the heart and the 
processes of resorption. Epstein showed that within a few hours 
after injection of salt solution the proportion of haemoglobin and 
red blood-cells were reduced. As salt solution has a dissolving effect 
on the red blood-cells, the injection of large quantities of the solu- 
tion may be harmful. 

Syringing of the Nose. — Instruments. — The best form of syringe 
for this purpose is an olive-tipped glass syringe. Some forms are 
made with a soft-rubber tip. The tip should be blunt, lest the nares 
be injured (Fig. 7). 

Fig. 7. 



Nasal syringe. Correct shape. 



The solution used is generally a normal salt solution. 
Method. — The patient is wrapped in a sheet or blanket, and held 
in the lap of a nurse, who holds a pus basin beneath the chin. The 



THE ADMINISTRATION OF DRUGS. 



67 



operator stands behind the patient. The syringe is held horizontally 
to the floor of the nares and the solution slowly injected into the 
nostril (Fig. 8). If successfully performed, the procedure results 
in the solution's coming out of the other nostril. There is no 
danger in the manoeuvre if carefully carried out. If the infant is 
too weak, the nares may be syringed with the patient in bed in the 



Fig. 8. 




Method of syringing the nose in the upright posture. 



recumbent posture. The nurse stands at one side, and the head is 
placed on the side, the pus basin beneath the nose, as shown in 
Fig. 9. A rubber fountain-syringe may be used in the same manner. 
Here also the position of the syringe is horizontal to the floor oi 
the nares. The syringe should be thoroughly boiled before and 
after using. An old syringe should never be used, no matter bow 
carefully it has been sterilized. 



68 



INFANCY AM) CHILDHOOD. 



Vapor Spray ; Calomel Inhalations in Acute Laryngeal Disease. — 

AVith infants and children the spray is not so useful an agent as 
steam vapor impregnated with balsams or turpentine, and combined 
at times with inhalations of the fumes of sublimed calomel. The 
spray cannot, as a rule, be used locally except with the most tractable 
children. With infants its use is not feasible. 

The vapor of steam impregnated with balsams or turpentine is 
very useful in all forms of acute laryngitis in which there is no 
bronchitis. I dispense with steam vapor if bronchitis is present. 
The mode of application in catarrhal or membranous croup is as 
follows: The crib is covered with a sheet suspended from four 
upright poles fastened to the corners of the crib. A tent is thus 
formed. The croup kettle is placed at one side of the crib, in such a 

Fig. 9. 




Method of syringing the nose in the recumbent posture. 



manner that the steam vapor escapes into the improvised tent. The 
vapor is medicated by placing in the kettle a teaspoonf ul of turpentine 
or thymol. This will be readily vaporized, ^o special apparatus 
has any advantage over the ordinary croup kettle. If calomel sub- 
limations are to be given, they should be combined with the steam 
vapor. Ten grains of calomel are placed in a spoon held over an 
ordinary candle, and the fumes led under the tent, the air of which 
is impregnated with steam vapor. The special devices sold for the 
sublimation of calomel may be used, but possess no advantage over the 
method described above (Fig. 10). Calomel sublimations are ex- 
ceedingly irritating, but they relieve the patient very promptly. They 
may be continued for forty-eight hours at intervals of two hours, 
without fear of salivation. 



THE ADMINISTRATION OF DRUGS. 



V) 



Stomach Washing. — One of the most valuable additions to our 
therapeutic armament within recent years is stomach washing in case 
of the nursing infant. 'No improvement has been made upon the 
method as first proposed by Epstein. The cases in which it is indi- 
cated are mentioned in another part of this work. The procedure 
is easiest of application to nurslings in whom there are no teeth or in 
whom very few teeth have erupted. With these subjects there is no 
danger of the catheter's being bitten, and there is no necessity of using 
a gag. With older children, however, a gag must be used when 
stomach washing is attempted. The Denhardt gag of the O'Dwyer 
set of intubating instruments is most suitable for this purpose. 

Fig. 10. 




Sublimer for calomel inhalation. 



Indications. — Washing out the stomach is principally indicated 
in the acute gastro-enteritis of the summer months. It is not bottle- 
fed infants alone that are attacked, but even breast-fed infants may 
be thus affected. The winter months also furnish their quota of 
these cases. One vomiting spell, as it is called, does not require 
attention. If, however, on suspension of the bottle or breast, vomit- 
ing continues and becomes uncontrollable, we proceed to stomach 
irrigation. Another indication is the so-called chronic dyspeptic 
vomiting. Those who advocate this method of treatment in these 
cases forget that, above all, the food is at fault, and must be regulated 
and modified. T do not favor washing the stomach in these cases. 

One washing is, as a rule, sufficient. I have rarely had to 
repeat it. If vomiting persists after the firsl washing, it is well to 
look for other conditions than gastro-enteritis, such as intussuscep- 
tion, as the cause of the vomiting. Stomach washing is also a favorite 



70 



INFANCY AXD CHILDHOOD. 



mode of treatment in cases of persistent vomiting due to spasm or 
stenosis of the pylorus. 

Acute drug poisoning or ingestion of any irritating fluid is quickly 
relieved by stomach washing. I have washed out many children 
who had been given an overdose of paregoric, or who had taken 
Paris green, turpentine, or other drug. If, as sometimes happens, a 
child accidentally swallows a caustic alkali, we should not introduce 
the tube into the oesophagus or stomach. 

Method. — A four-ounce funnel, a piece of rubber tubing two and 
a half feet long, and a Xo. 14 rubber catheter are the instruments 

Fig. 11. 




Apparatus for washing out the stomach. 



necessary. The rubber tubing is attached to the funnel, and by 
means of a piece of glass tubing to the catheter, as in Fig. 11. 
About a quart of normal saline solution is needed. The temperature 
of the water should be at least 100° F. The operator needs one 
assistant. 

The infant is completely undressed, and is then wrapped in a 
blanket, the diaper having first been applied. The hands are tucked 
in with safety-pins. The infant having been laid recumbent on a 
table, the operator, standing on the right, introduces his left index 



E- 

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Oh 




TEE ADMINISTRATION OF DRUGS. 71 

finger into the mouth and depresses the tongue (Plate L). The 
catheter, moistened with water, is now introduced and passed back- 
ward. With gentle urging the catheter passes easily into the (esopha- 
gus. There is no likelihood of the catheter's passing into the larynx 
and trachea. About six inches of the catheter are introduced. The 
funnel is depressed and the stomach contents are first allowed to 
flow out. The funnel is then raised about two feet above the patient, 
and the assistant slowly pours the saline solution into the funnel, the 
fluid flowing into the stomach. Before the funnel is completely 
emptied, it is lowered and the stomach contents siphoned out. This 
operation is repeated several times, until the water returns quite 
clear. If during the stomach washing the fluid should be ejected 
from the stomach in the act of vomiting, it will easily flow out of the 
mouth if the infant is recumbent. There is not the slightest danger 
of aspiration of the fluid into the trachea. I think the recumbent 
position is superior to the sitting posture advocated by some clinicians. 
A young infant is unable to sit up of its own accord. 

The introduction of the tube is not so easy for the infant in the 
sitting posture as in the recumbent position. The tube being intro- 
duced, the stomach contents sometimes refuse to flow out because 
mucus and food particles obstruct the lumen of the catheter. In 
such cases the catheter is withdrawn, and washed out. The catheter 
is then pinched with the fingers in such a manner that some of the 
water or washing solution remains in the catheter. It is then intro- 
duced into the stomach. In this way the catheter, being filled with 
fluid, mucus and food cannot obstruct the lumen of the tube before 
siphonage is begun. Fluid can then readily be introduced into the 
stomach. These difficulties occur in cases in which there is a large 
amount of mucus in the stomach. The finger should always bo 
retained in the mouth. By grasping the catheter with the thumb 
and index finger of the right hand, prying open the mouth at the 
same time, we prevent pressure on the catheter during the washing. 
If the infant has upper and lower incisors, the catheter must be held 
at one side of the mouth and the mouth kept open by means of the 
index finger held in the angle of the mouth. The method described 
above has been followed by me for years. I have never had an 
accident. 

Gavage. — Gavage is a method of forced feeding by means of the 
stomach-tube. I have practised this method of feeding infants and 
older children suffering from pneumonia or typhoid fever, who were 
delirious or unconscious. It is also a method which has been pro- 
posed in cases of uncontrollable vomiting and T have utilized it in 
patients suffering with spasm of the pylorus. 

The method of procedure is similar \o that used in stomach wash- 



72 INFANCY AND CHILDHOOD. 

ing. It is best not to introduce the catheter through the nose, but 
to keep the mouth open with some device. If the catheter is passed 
through the nose, no food should be introduced into the funnel until 
we are sure the feeding-tube is in the stomach. With older children 
a tube passed through the nose may pass into the larynx. If it 
has done so, a hissing sound will be heard. Aphonia will also be 
present. In infants and young children the glottis is small, and a 
full-sized catheter will not readily pass into it. After the tube is 
in the stomach the prescribed amount of liquid food is introduced 
and the tube rapidly withdrawn. The feeding may be repeated every 
four to six hours. 

Rectal Enemata; Irrigation; Enteroclysis. — The bulk of an or- 
dinary enema, introduced in order to empty the bowel, should be 
from 2 to 4 ounces. A Davidson's bulb syringe should not be used. 
A JSTo. 16 or No. 18 catheter is attached to the nozzle of an ordinary 
four-ounce hard-rubber syringe. The infant or child is placed on its 
side, with a rubber sheet under the buttock. The tip of the catheter 
is oiled and passed well within the anal ring. The catheter is then 
attached to the nozzle of the syringe containing the fluid to be injected, 
and the fluid is gently thrown into the rectum. An enema commonly 
used is soap-water, with the addition of a tablespoonful of castor oil 
or glycerin. 

The high rectal enema, irrigation, or enteroclysis, is given in 
all forms of summer diarrhoea, dysentery, and in typhoid fever. It 
is also indicated in cases in which there are symptoms of collapse, in 
exhausting diseases, in nephritis, and after operations. It was for- 
merly a method employed to reduce an intussusception in its early 
stages but is not now in vogue. In diarrhoea, the object of the high 
rectal enema is twofold — to clear out the faeces from the lower 
bowel, and to supply fluid to the depleted circulating blood, thereby 
stimulating the heart. The latter is the main object in practising 
enteroclysis in states of exhaustion and after operations. In sup- 
pression of urine we aim to supply fluid to the kidneys and stimu- 
late the circulation. According to Kemp, the high rectal enema 
is one of our most useful diuretics. 

The solution employed is the Cantani saline solution (sodium 
carbonate, 3.0; sodium chloride, 4.0; water, 1000). At least a 
quart is injected. The temperature of the solution for simple wash- 
ing of the gut, as in diarrhoea, should be that of the body. In 
nephritis or collapse the temperature should be at least 108° to 
110° F. (42.2° to 43.3° C). 

The instrument employed may be a bag fountain syringe, of a 
quart capacity, to which is attached a small calibre soft-rubber 
rectal tube or a catheter, or the rubber tubing and catheter may be 
attached to a six-ounce glass funnel. 



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X 
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> 

3 



THE ADMINISTRATION OF DRUGS. 1Z 

The patient is completely undressed and laid on a table on the 
side, with the knees flexed and the buttocks near the edge. A 
rubber sheet placed underneath the buttocks leads into a pail, so that 
the returning water will drain off (Plate II.). The buttocks are 
placed slightly higher than the trunk. The catheter or rectal tube 
is oiled and introduced two or three inches into the rectum, the water 
allowed to flow, and the tube passed higher up. Sometimes there is 
an obstruction to the passage of the tube, and then it is necessary to 
introduce the finger cautiously into the rectum alongside of the tube 
and guide it past the upper sigmoid ring. The tube may thus be 
passed from six to eight inches into the gut. It is seldom necessary 
to introduce it higher, as the water will find its way into the colon. 
About a pint or more of water is then allowed to flow into the gut. 

It is not necessary to compress the anus around the catheter to 
prevent the escape of the fluid. Some of the fluid may escape along- 
side the catheter. In some forms of exhausting diarrhoea a portion of 
the saline solution should be left in the gut after it has been well 
irrigated, in order to stimulate the heart and supply fluid to the 
circulation. Two irrigations may be necessary in the twenty-four 
hours, rarely more. In typhoid fever one low irrigation is given 
daily. In some subjects, if the irrigations are continued too long, 
hypergemia of the mucous membrane results. Clinically, this is 
manifested by a continuance or increase of mucus in the washings, 
and also by the occasional presence of blood. In such cases the 
enemata should be suspended. 

In nephritis complicating scarlet fever, rectal irrigation is one 
of the recognized methods of stimulating the secretion of the kidney, 
which result, according to Kemp, begins twenty minutes after the 
fluid is introduced into the gut. With adults the Kemp tube is 
used, but with children, who are difficult to keep quiet, continuous 
irrigation is not feasible. In these cases high enteroclysis is given 
in the ordinary manner, as much of the solution as possible being- 
retained in the rectum. This procedure may be repeated two or 
three times daily. In giving ordinary enteroclysis the bag of the 
fountain syringe or funnel should not be held more than three feet 
above the body of the patient, lest the pressure be too great. About a 
pint of fluid at a time is allowed to flow into the gut ; the catheter is 
then disconnected, and the contents of the gut allowed to flow out. 

A stimulating enema is given after an operation, or when symp- 
toms of collapse appear in any acute illness. Only small quantities 
of solution are allowed to flow into the rectum. A formula in use 
in my wards is the following: 



74 INFANCY AND CHILDHOOD. 

Whiskey 5j- 

Caffeine . gr. i. 

Tint, digital gtt. ij. 

Sol. sodium chloride (0.6 per cent.) ^j. 

Temperature, 102°-10o° F. 

Nutritive enemata are used when for any reason, such as uncon- 
trollable vomiting, the stomach must be given complete rest. Soma- 
tose solution, of one teaspoonful of somatose dissolved in eight ounces 
of cold water, is given lukewarm §ij at a time, every four hours. 
Or, ext. pancreatis, gr. v ; sod. bicarb., gr. ij ; water §iv ; milk, §xvj ; 
with or without the addition of an egg. Give §ij or giij. These 
enemata should be given slowly and high up, and in small quantities 
at a time. 

For constipation in cases in which faeces have become impacted 
and are in the form of hard scybala the following is excellent : 

Olive oil 3,ij. 

Glycerin 5j- 

This should be injected to be followed after a few hours by an ordi- 
nary enema of soap-water. 

In cases of cardiac disease with uncontrollable vomiting, digitalis 
is administered with excellent results by the rectum. The requisite 
dose of infusion is placed in simple water up to the bulk of two 
ounces and is then introduced high in the rectum. This may be 
repeated three times daily for days. 

Lumbar Puncture. — Lumbar puncture was first practised by 
Quincke. It is to-day one of the' most useful adjuncts to the methods 
of diagnosis in acute and chronic forms of cerebral and spinal dis- 
ease. Its future usefulness as a therapeutic measure is not clearly 
established, but will probably lie in relieving symptoms due to pres- 
sure, removing the excess of inflammatory exudate in the various 
forms of meningitis, and introducing sera and curative agents into 
the subarachnoid space. 

The Normal Cerebrospinal Fluid. — Xormal cerebrospinal fluid is a 
clear colorless fluid having a slightly alkaline or neutral reaction. Its 
specific gravity varies from 1007 to 1009. It contains from 0.05 
to 0.1 per cent, of albumin (Quincke, Rieken, Pfaundler), and be- 
cause of the presence of sugar (0.05 per cent.) has a slightly re- 
ducing action on copper. It does not coagulate spontaneously. If 
centrifuged, a microscopic sediment of a few endothelial cells and 
small mononuclear cells and lymphocytes may be obtained. The 
cerebrospinal fluid is normally under a pressure of from 5 to 20 
millimetres of mercury or 40 to 150 mm. of water. The pressure 
in infants is lower than that in children. The causes of the variations 
of pressure and the nature of the conditions under which they occur 



THE ADMINISTRATION OF DRUGS. i 

have not as yet been determined. Respiration causes a deviation of 
fully^6 millimetres of mercury in the manometer column. 

Abnormal Conditions. — The cerebrospinal fluid will in pathological 
states vary in respect to specific gravity, composition, appearance, 
and in the amount of sediment contained. The pressure in the sub- 
arachnoid and cerebrospinal spaces will also vary in different forms 
of disease. It is increased in inflammatory states, hydrocephalus, 
hemorrhage, tumors of the brain, abscess, acute alcoholism, eclampsia 
and epilepsy. 

Specific Gravity.- — The specific gravity in tuberculous meningitis 
varies from 1003 to 1011 (Lenhartz), in cerebrospinal meningitis 
from 1005 to 1012 (Pfaundler). 

Gross Appearances. — The gross appearances of the fluid obtained 
by lumbar puncture may be changed by the admixture of blood. 
Blood may come from the puncture wound or may have been in the 
canal previous to puncture as a result of a hemorrhagic pachymenin- 
gitis or of some form of cerebrospinal meningitis, traumatism, or 
apoplexy with rupture into the ventricles. The wounding of veins 
either in the tissues or in the cauda equina may cause an admixture 
of blood. The quantity of blood may be just sufficient to tinge the 
fluid or the blood may be almost pure. It is not possible to determine 
whether the admixture of blood is or is not the result of accidental 
puncture of a vessel unless, as in pachymeningitis or traumatism, 
light is thrown on the matter by the history of the case and the 
presence of blood on repeated puncture. The accidental admixture 
of blood is unfortunate, since it obscures the microscopical diagnosis. 
The hemorrhage into the spinal canal as a result of the operation of 
lumbar puncture is never alarming or of serious import. 

Tuberculous Meningitis. — Tuberculous meningitis changes the 
gross appearance of the fluid obtained by lumbar puncture. The fluid 
may be quite clear, exceptionally cloudy, opalescent, or in rare cases 
purulent. As a rule, however, it is clear in the early stages of the 
disease and cloudy in the later period. If the test-tube is held in a 
strong light, there may be seen, in a clear or cloudy fluid, myriads 
of highly refracting particles resembling the motes in a sunbeam 
(Moser, Bernheim, Pfaundler). The appearance is quite character- 
istic. It was first explained by Lichtheim, as the result of spontaneous 
coagulation. If a test-tube of the fluid obtained by lumbar puncture 
is placed in the upright position in an ice-box, there is found after 
twenty-four hours, a fully formed cobweb-like, funnel-shaped coagu- 
lum, beginning a little below the surface of the fluid and extending 
downward, the broader part of the funnel being above. Axscording 
to Pfaundler, this coagulum is of diagnostic import. I have relied 
on its appearance in fluid which was no! contaminated with blood. 



76 INFANCY AND CHILDHOOD. 

and found it of great value. The formation of the coagulum begins 
after the fluid has stood for two hours, and is fully completed by the 
following dav. It is usually found from eie,ht to twelve days before 
death. 

Suppurative Meningitis. — In this form of meningitis, the fluid 
obtained by lumbar puncture is purulent, opalescent, grayish-white, 
grayish-yellow, or brownish (hemorrhagic). Exceptional cases give 
a clear fluid. There may be a spontaneous coagulum resembling 
that seen in tuberculous meningitis. 

Epidemic and Sporadic Cerebrospinal Meningitis. — In the early 
stage of this disease, the fluid may be quite clear with suspended 
microscopic sediment. It may also be cloudy or thick, creamy or 
bloody. It may at first be clear, and later in the disease become 
purulent (Councilman). 

Chronic Hydrocephalus. — This gives a clear fluid with no sus- 
pended particles visible to the eye, although microscopically there may 
be leucocytes. Pfaundler in one of his cases obtained a fluid which 
was cloudy because of the admixture of leucocytes. 

Brain Tumors. — Tumor of the brain gives a clear fluid. I have 
had such cases. 

Sediment. — This feature will be fully discussed under the sec- 
tions devoted to tuberculous meningitis and cerebrospinal meningitis. 

Cytology. — The cytology of the fluid in an acute inflammation is 
as a rule polynuclear, whereas in a chronic process there is an excess 
of lymphocytes. Organic disease of the meninges such as syphilis 
will cause a lymphocytosis. Pathological fluids contain small mono- 
nuclear lymphocytes, polynuclear leucocytes, transitional forms, large 
lymphocytes (mononuclears) with basophile granulations, so-called 
plasma-cells, and finally endothelial cells. In addition to cellular 
elements the fluid may contain bacteria. These will be discussed 
under the various diseases. Here we may simply mention the pres- 
ence of the pus organisms, Staphylococci, Streptococci of various 
varieties, Pneumococci, Typhoid bacilli, Coli bacilli, Streptococcus 
mucosus, Tetanus bacillus, Influenza bacillus, Bacterium lactis 
aerogenes, Bacterium coli immobilatus and capsulatus, Saccharomyces 
glanders, Meningococci, and Tubercle bacilli. In fact almost any 
form of bacteria, as well as protozoan bodies, such as trypanosomes, 
have been found in the cerebrospinal fluid. 

Pressure. — The pressure under which the cerebrospinal fluid is 
retained in the subarachnoid space and in the spinal canal is in- 
creased in the various forms of meningitis. This is especially true of 
tuberculous meningitis, in which the pressure may reach 110 mm. of 
mercury. In this disease the pressure increases from the initial 
period to that of pressure symptoms, and diminishes toward the close 



THE ADMINISTRATION OF DRUGS. 



77 



of the disease — the stage of paralysis. Ventricular involvement gives 
the highest pressure figures. The following figures are taken from 
Pfaundler's tables: 



First stage 48 m.m. of mercury. 

Stage of pressure 52 m.m. ' ' 

of paralysis 24 m.m. " " 



Iii suppurative meningitis, the pressure varies from 10 to 37 m.m. 
of mercury ; in cerebrospinal meningitis, from 24 to 50 m.m. ; in 
hydrocephalus, from 6 to 60 m.m. ; in tumor of the brain, from 3 
to 52 m.m. (Quincke, Slawyk, Pfaundler). 

The presence of an increased amount of albumin in pathological 
states has been noted by Wentworth, Quincke, and Pfaundler. In 
tuberculous meningitis it may reach 0.3 per cent. ; in purulent menin- 
gitis, 0.6 per cent. 

The Operation of Lumbar Puncture. — Instrument. — The instrument 
consists of a trocar and canula such as is employed in tapping cavi- 
ties. The best form of instrument is that devised 
by Quincke (Fig. 12). The canula should be at 
least one millimetre in diameter. In order to de- 
termine the pressure, the manometer is used. This 
consists of a piece of ordinary glass tubing with 
an attachment of soft rubber tubing. The manom- 
eter is useful to determine the millimetres of 
fluid as indicative of pressure in the ventricles and 
subarachnoid space. 

In infants a rough way of estimating the pres- 
sure is through the tenseness of the anterior fonta- 
nels, and in all children the force with which the 
first few drops of fluid escape from the canula. 

Indications for Lumbar Puncture. — Lumbar punc- 
ture is performed for diagnostic and therapeutic 
purposes in all cases in which there are symptoms 
which very closely simulate meningitis, or in 
which we think meningitis is actually present. 

I have also performed lumbar puncture re- 
cently for the relief of symptoms of so-called men- 
ingism, knowing that no meningitis was present. 

Lumbar puncture is performed as a therapeutic procedure in 
cases of meningism, to relieve pressure, or at times in the condition 
of status epilepticus; in all forms of meningitis; and as a therapeutic 
procedure in chronic hydrocephalus. 

It has recently been advanced by the otologists as exceedingly 
useful in cases where meningitis is suspected as an extension from 
inflammation of the ear structures. 




The Quincke noodle for 
lumbar puncture. 



78 INFANCY AND CHILDHOOD. 

The decision to perform lumbar puncture in private practice is 
not always easy on account of the dread with which the laity regard 
all procedures of this nature. 

In pneumonia where there may be a suspicion of pneumococcus 
meningitis and where there are signs of increased cerebral pressure as 
evinced by cerebral symptoms, the persistence of such symptoms may 
justify the physician in performing lumbar puncture. 

Indefinite cerebral symptoms such as headache, restlessness, and 
convulsions of a general or transitory nature are not indications for 
lumbar puncture. 

On the other hand, even very mild cases of meningitis, with indefi- 
nite sopor, muscular weakness, delayed reflexes at the knee, marked 
emaciation, and fever without even marked rigidity of the neck, may 
justify the procedure of lumbar puncture on the ground that if a 
meningitis is present we should endeavor to give the patient the 
benefit of the therapeutic serum as early as possible. 

Formerly it was the custom to refrain from puncture in doubtful 
cases ; to-day we prefer to puncture in these cases for reasons before 
mentioned. 

Cases with meningeal symptoms in which there is the history of a 
blow are proper subjects for puncture, since it may be necessary to 
exclude either meningitis or abscess of the brain. 

More detailed discussion of puncture for all forms of meningitis 
and hydrocephalus will be taken up in chapters devoted to those 
subjects. 

Place of Puncture. — The puncture is made in the space between 
the third and fourth or the fourth and fifth lumbar vertebra?. This 
point is obtained by palpating the crests of the ilium; an imaginary 
tangent to these crests strikes the fourth space. The space above 
this imaginary line will, as a rule, be found to be the third space. 
Puncturing the canal in the space between the sacrum and coccyx 
or in the lower sacral space offers no advantages either anatomically 
or from a diagnostic standpoint. 

Method. — General anaesthesia is necessary only in strong muscu- 
lar individuals to reduce resistance. Children who can be held do 
not need anaesthesia local or general. The back of the patient is 
carefully scrubbed with green soap, then washed with alcohol and 
ether, and finally with sublimate. The patient is laid on either side 
according to the convenience of the operator. The spine is curved 
so that the spinous processes may be distinctly seen and palpated 
(Plate III.). ^vTo considerable pressure should be brought to bear 
on the neck, since in cerebrospinal meningitis or in the basilar form 
of meningitis in which there is opisthotonos, serious injury to the 
neck may be caused. The spine is curved from the shoulders and 



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THE ADMINISTRATION OF DRUGS. 70 

pelvis. The needle, having been previously boiled, is introduced in 
the median line between the spinous processes at right angles to a tan- 
gent to the spine (Plate IV.). When it is in the canal, it is perceived 
that there is a lack of resistance, and that the point of the instrument 
is free. The canula is withdrawn and the first drops caught in a 
sterilized test-tube. A second test-tube is substituted for the first 
after a few drops of fluid have been ''allowed to flow out, and from 10 
to 50 c.c. of fluid are withdrawn, the amount varying with the pres- 
sure. If the fluid flows drop by drop, 20 c.c. are sufficient for diag- 
nostic purposes and also to relieve the pressure. If there is opistho- 
tonos and the fluid does not flow well at first, cautious straightening 
of the neck will facilitate the outflow. In infants the fontanelle is a 
good guide in gauging the pressure. As soon as a few cubic centi- 
metres of the fluid have been withdrawn, the fontanelle will be felt 
to be considerably flattened and relaxed or even depressed. 

If determination of pressure is desirable, the manometer tubing 
should be immediately attached as soon as the obturator to the canula 
is withdrawn, care being taken not to allow any of the fluid to es- 
cape, for this would invalidate the determination of pressure. The 
manometer is held at right angles to the spine in an upward direc- 
tion as the patient lies recumbent. The fluid from the spinal canal 
will rise in the manometer to the point where the glass is crooked ; it 
must not be allowed to flow over the curve ; the measurement is then 
taken of the height of the column of liquid. After this is done the 
manometer tube is lowereel and the fluid is allowed to escape. In 
ordinary lumbar puncture the determination of pressure is not 
necessary. Heubner has withdrawn 100 c.c, but the removal of such 
large quantities is unnecessary and may be followed by hyperpyrexia 
and collapse. I rarely withdraw more than 30 to 50 c.c. If there is 
a dry tap, the canula should be withdrawn and a second attempt 
made on the following day. A dry tap may be caused by a fibrin 
clot or by the falling of the cauda equina in front of the opening of 
the canula. The fluid may be viscid and refuse to flow. In that case 
the fluid should not be aspirated with a syringe, since in the experi- 
mental laboratory this method has been proved to be hazardous. After 
puncture, the canula is rapidly withdrawn and the wound dressed 
with sterile gauze. 

Dangers of Lumbar Puncture. — Lumbar puncture if carried our as 
above 1 indicated is rarely followed by ill effects or death. But there 
are enough cases of fatal issue 1 during or after the Lumbar puncture 
in the literature 1 to make 1 us mindful of the fad that in exceptional 
cases, especially when patients have been ill for some time, and in 
cases of tumor of the brain, such an issue is always possible. 

Therefore if lumbar puncture is performed in cases where tin re 



80 



INFANCY AND CHILDHOOD. 



Fig. 13. 



are reasons to assume the existence of a cerebral tumor, those inter- 
ested should be warned of the possibility of an untoward issue. 

Introduction of Fluids Containing Drugs or Sera Into the Spinal Canal. 
■ — !Now that cerebrospinal meningitis is treated with sera by the so- 
called sub-dural method, it becomes necessary after 
the withdrawal of the fluid in cases of meningitis 
to introduce the therapeutic serum into the canal. 
As a rule we introduce in quantity as much as 
we have withdrawn from the patient. It is cus- 
tomary in some quarters to attach a syringe con- 
taining the therapeutic serum or fluid to the canula 
of the puncture needle, and thus slowly inject the 
fluid into the canal. This is not as desirable a 
procedure as using a so-called Quincke funnel for 
this purpose. The Quincke funnel consists of a 
small glass test-tube, drawn out into a funnel- 
shaped point, which is attached to a piece of tubing 
(Fig. 13). As soon as the fluid has escaped to the 
desired amount from the spinal canal, the tubing- 
is attached to the tip of the canula, and the funnel 
being filled with the therapeutic agent, is somewhat 
depressed below the level of the opening in the 
canal in order to allow the air which may have 
been in the tubing to escape. The canula is then 
raised slightly, and it will be observed that the 
fluid will flow quite freely into the spinal canal.. 
The patient remains in the recumbent position 
during the operation, as has been indicated in the 
paragraph on technique. 

All fluid introduced into the spinal canal 
should have been previously warmed carefully to 
the temperature of the body, and should be intro- 
Quincke funnel, tub- duced slowlv. Rapid introduction of the fluid will 

ing and needle at- x 

tacned for introduc- cause, m exceptional cases, collapse and especialiv 

ing serum or fluids . . x ^ . mi • 

into the subarachnoid if a syringe is used cessation oi respiration, lnis 
has happened twice in the author's experience, 



though no fatal issue resulted, 
the funnel. 



It has not occurred with the use of 



SECTION II. 

NUTRITION AND INFANT-FEEDING. 

PRINCIPLES UNDERLYING THE PROCESSES OF NUTRITION. 

There is no division of pediatrics which exceeds in importance 
that of infant-feeding. In fact the subject of infant-feeding is not 
only difficult to master, but requires thorough study and experience 
to carry it to a successful issue. The practitioner, therefore, will 
find that it is absolutely necessary for him to understand the prin- 
ciples underlying the art of infant-feeding, in order to attain any 
success in practice in this field. Though great advances have been 
made in the study of infant-feeding in the past decade, we cannot say 
that the art of applying certain principles of nutrition to the feeding 
of infants has attained its highest perfection. We cannot explain 
why one infant will thrive, whereas another, fed according to the 
same method, will fail to thrive and lose ground. 

To a certain extent the subject of infant-feeding is still empirical, 
although it may be said that empiricism is gradually but surely dis- 
appearing from this field of pediatrics. It is the exceptional infant 
which to-day refuses to thrive, and puzzles the most brilliant master 
of the art, but the vast majority of children can certainly be fed 
according to principles well established and laid out at the disposal 
of the general practitioner. 

If we study these principles of nutrition closely we shall see that 
they must to a certain extent conform to what is known to take place 
not only in the body of the infant, but also in that of the adult. 
There are certain exceptions which must be made as regards the 
infant, on account of its rapidly growing organism and the fact that 
the cells of the body are not only being replaced rapidly, but the 
tissues at the same time are undergoing rapid increment. As that 
of the adult, the body of the infant and child is constantly suffering 
a loss of its principal elements, consisting of water, albumin, fat. 
and mineral salts. This loss will vary within wide limits, accord- 
ing to the needs of each individual subject. The infant body must 
take in sufficient nourishment not only to make up for the constant 
loss and destruction of cell life, but also for the increase and growth 
of the body and development of various tissues, in this respect dif- 
fering from the adult. The loss of nitrogenous substances and fat 
must be made up by equivalents in the food: at the same time in the 

6 81 



82 NUTRITION AND INFANT FEEDING. 

infant and child enough must be furnished to allow for the rapid 
increase of weight and the growth of tissue throughout the body. 

There are other substances, such as collogen, chondrogeu, keratin, 
mucin, and lecithin, which are needed in the infant's economy as 
well as in that of the adult, and these are excreted by the infant and 
child as in the adult. If fat and albumin are taken in sufficient 
quantity into the system, the loss in these substances is compensated 
for by the splitting up of the nitrogenous and fatty elements of the 
food. 

It will enlighten the student to familiarize himself with the role 
played by the various food elements in replacing the loss of tissue 
in the economy. These primary food elements are principally water, 
mineral salts (inorganic and ash residue), proteids, or albumin, fat, 
and carbohydrates. 

Water. — Water plays by far the principal role in the composition 
of the body. The tissues of the body contain from 66 to 70 per 
cent, of water in the newborn infant and child, as compared with 
64 per cent, in the adult. It exists in this high percentage in most 
of the organs of the body, with the exception of the bones, cartilage, 
teeth, and fatty tissue. The remaining organs, if these be excluded, 
will contain 78 per cent, of water. Water is not only essential to 
the adult body, but is a very important element of nutrition in in- 
fants. We see this exemplified in disease, especially when the drain 
on the system is great and the loss of fluids of the body is consider- 
able, as in cholera infantum, or in intestinal disease, acute and 
chronic. Infants show the drain of water from the economy very 
rapidly, and our treatment in disease is directed in a great many 
instances to supplying the loss oi; water caused by the diseased con- 
dition. The circulation of the blood and lymph depends on the pres- 
ence of a fixed percentage of water; in the former case 78 per cent., 
in the latter 96 per cent, of these tissues is composed of water. Di- 
gestion, both in the adult and the child, must have for its successful 
completion a certain amount of water element. Muscular and nerve 
force are greatly dependent on water and are regulated by it. 

The body excretes water through the urine, the faeces, the lungs, 
the skin, and the amount excreted varies widely, not only in the 
adult, but in the infant and child. 

It is not our aim here to enter into any specific details of the 
role played by water in the economy, but from what has been said 
it can be seen that inasmuch as fully 86 per cent, of the breast-fed 
infant's food consists of water, nature has put great store by this 
element of foodstuff which is taken into the infant's body daily. 
Moreover, water given in disease will sometimes maintain life, but 
it cannot maintain the proper nutrition of the body without the 



PRINCIPLES UNDERLYING PROCESSES OF NUTRITION. 83 

addition of other elements of food. This is seen in the treatment 
of gastro-enteritis. We may tide over a critical period in the disease 
by the administration of water exclusively, without endangering life 
through starvation. During this period, however, the nitrogenous 
waste of the body is not replaced by any equivalent article of food, 
and though we may continue on a water diet for a little while, it 
becomes imperative after a time to add other substances to the food. 

Mineral Salts. — Mineral salts exist in most of the tissues of the 
body and in all organized tissue which, when burnt, leaves an ash 
residue. Sodium, potassium, lime, magnesium, and phosphorus, 
with a trace of iron, are the principal mineral substances found in the 
body. Just as water is necessary to the maintenance of the nutrition 
of the body, so are the mineral salts. The actual growth of the child 
in the first six months amounts to 150 to 300 grammes; in the fol- 
lowing six months, 100 to 200 grammes per week. In the second 
year the body-weight is increased by 50 to 100 grammes per week, 
and from this time on the increase declines. The skeleton in the 
first year increases fully 2.2 pounds, or one kilo, in weight, and the 
earthy phosphates being an important element in the composition of 
the bones, 3.5 grammes of phosphate of calcium are used every week 
during the first year by the skeleton. 

This great demand of the skeleton for lime salts is met by the 
food of the infant — the milk — much better and in a more assimi- 
lable state than by any food taken by the adult subject. The muscles 
also need a certain amount of lime salts, and a dearth of mineral 
salts becomes evident much more quickly in the infant and child 
than it does in the adult. We see this exemplified in artificially fed 
infants, whose food (cows' milk) is not as well assimilated as is the 
mother's milk by the naturally fed infant. Whereas 800 c.c. of 
mother's milk contain 1.2 grammes of potassium phosphate, 0.2 
grammes of lime phosphate, 0.6 grammes of sodium chlorid, and 2.5 
milligrammes of iron, and these are completely assimilated by the 
infant, the same salts in cows' milk are excreted to a great extent 
by the intestine (Bunge), and for this reason, in part, rachitis and 
disturbances of nutrition of the bones are very common in artificially 
fed infants. 

Proteids. — Next to water, according to Munk, the most important 
constituents of the body are the proteids ; they make up 10 per cent, 
of the tissues. The proteids in the food not only replace the general 
nitrogenous loss of cell tissue in the body, but with other substances, 
the so-called proteid-saving elements of the food, such as far. add to 
the general nitrogenous store in the body. Nitrogenous cell waste 
can be replaced only by the proteids of the food. Growth of body 
is accomplished by the proper supply of albumin in the (ood. Other 



84 NUTRITION AND INFANT FEEDING. 

substances, such as fat, added to the albuminous substances of the 
food may replace nitrogenous waste in the body; increase of weight 
or growth can be accomplished only by the proteid elements of the 
food. 

The bone tissue, cartilage, tendon, connective tissue, need pro- 
teids also, as has been stated above, to replace the waste and accom- 
plish the growth of these tissues. The breast-fed infant obtains in 
its food a casein and also, in small quantities, lactalbumin. From 
these the body forms not only the nitrogenous cell elements, but 
mucin, chondrin, glutin, elastin, keratin, which are derivatives of 
albumin, and whose mode of formation is still obscure (Munk). 

Fats. — Animal fats are composed of varying proportions of olein, 
palmitin, and stearin. Their presence in the body varies, within 
certain limits, from 9 to 23 per cent, of the body-weight. Fat is 
found in the body in the form of fat-deposits. It is deposited under- 
neath the skin, in the muscle, in the nerve tissue, around the various 
organs of the body. It plays an important role in the maintenance 
of the warmth of the body and exerts a non-conducting role, pre- 
venting radiation. As a food it cannot replace the proteids. Fat 
combined with proteid substances in the food may, however, act as 
a nitrogenous-saving substance. Thus, in muscular work the body 
needs a great amount of fat. If combined with the proteids, nitrog- 
enous waste is saved and fat is burnt up in doing the muscular work, 
and it may even, if taken in sufficient quantities, cause an accumu- 
lation of fat in the body. To cause growth in nitrogenous tissue, 
however, the presence of a sufficient amount of proteid in the food is 
absolutely necessary. Thus, while fat and albumin may replace 
waste caused by muscular action, both in the fatty and nitrogenous 
tissues of the body, fat cannot add to the nitrogenous growth of 
cell tissue. 

The infant and child obtain the fatty elements of the food in the 
milk. Whereas 97.5 per cent, of the fat in mother's milk is assimi- 
lated, only 93.5 per cent, of the fat of the cows' milk is assimilated 
by the infant. The artificially fed infant, therefore, is deprived of 
an important food element to the extent indicated, and in many cases 
assimilation of fats in the artificially fed infant is even much more 
imperfect in practice than is indicated by the percentage named. 
For in some infants, if the fat in the cows' milk is increased beyond 
a certain percentage, symptoms of intestinal indigestion manifest 
themselves in a so-called fat diarrhoea. In other infants the difficul- 
ties of fat assimilation are shown in inordinate constipation and 
ansemia, especially if the percentage of fat in the food is in excess 
of 4 per cent. Such infants must be fed on a limited amount of fat 
because of the difficulty of assimilation of fat of cows' milk. 



METABOLISM IN THE NURSING INFANT. 85 

Carbohydrates.- — According to Munk, carbohydrates exist in 
various tissues of the body, most abundantly in the liver, in the form 
of glycogen and grape sugar ; in the human milk, in the form of milk 
sugar, 3^ to 9 per cent., in the muscles, in the form of glycogen, 0.3 
to 0.9 per cent., with some grape sugar. The blood and lymph con- 
tain a small quantity of grape sugar (0.1-0.15 per cent.). We find 
glycogen in all growing tissues, and the formation of glycogen seems 
to be a function of the young cell. 

The infant obtains its carbohydrates for the most part from the 
milk, where they exist in the form of milk sugar. Milk sugar as 
contained both in human and in cows' milk is assimilated by the 
infant completely, so that in this respect the infant is not deprived 
in artificial feeding of any food element. 

Carbohydrates play much the same role in the economy as do 
the fats in saving nitrogenous waste. Whereas we can make up 
to a certain extent nitrogenous waste by the addition of fats and 
carbohydrates to the food, the nitrogenous substances of the body 
themselves can be reproduced only by nitrogenous proteid substances. 
It is self-evident, therefore, that in infant-feeding, though we may 
produce fat by carbohydrates, saving to a certain extent nitrogenous 
waste, we cannot do this for any length of time without producing 
an actual proteid starvation unless we supply with the carbohydrates 
and the fat a certain amount of proteids. 

We see this well illustrated in substitute infant-feeding in cases 
of difficult proteid digestion. We can aid digestion of the proteids 
by the addition of carbohydrates. We can even cause the formation 
and deposit of fat to a great extent by the addition to the food of car- 
bohydrates. We can save nitrogenous cell waste by the addition of 
carbohydrates to the food. If we continue this mode of feeding for 
any length of time we can see clinically the effects of the dearth of 
proteids on the economy. The infants after a period of time do not 
increase in weight, the tissues of the body suffer in nutrition, and 
ansemia appears. We then must supply with the carbohydrates an 
increased amount of proteids. 

METABOLISM IN THE NURSING INFANT. 

The principles of metabolism and nutrition which have been 
established in the adult apply in a general way to the nursing infant. 
In the adult the food supplies the waste and maintains body-heat and 
energy, but in the infant it must also furnish, in addition to these, 
the material for body-growth. The main physiological character 
istic, therefore, of infancy and childhood is that it is a period of 
growth, and the younger the infant the greater the growth. 



86 NVTEITION AND INFANT FEEDING. 

Milk, the food of the breast-fed infant, contains all the necessary 
food elements to maintain nutrition, produce energy, warmth, and 
to aid in cell-growth. In considering metabolic processes in the 
infant we express the energy and warmth-producing equivalents of 
the food introduced into the body by the term calories. A calorie 
is the heat produced by raising 1 kilogram of water, 1° C, and is 
the unit of heat. In the infant there is a deficit, as in the adult, of 
10 per cent, between the raw calories (food) introduced into the body 
and the actual number of calories produced. In other words, all the 
food is not absorbed. We do not know as yet how much to allow in 
estimating the number of caloric equivalents for the excreta, urea, 
carbonic-acid gas, and water. With the above defects yet to be eluci- 
dated by further investigations, we can present the following facts : 

A breast-fed infant, three months of age, weighs 5 kilos, takes 
800 c.c. of breast milk in the twenty-four hours, and increases 0.25 
to 0.35 grammes a day. A litre of human milk contains: casein 
16 grammes, fat 35 grammes, milk sugar 65 grammes. The adult, 
on the other hand, takes daily 1.7 of proteids, 0.85 of fat, 7.5 of 
carbohydrates per kilo of body-weight. The nursing infant, there- 
fore, takes per kilo of body-weight twice as much proteids and three 
times as much fat as the adult, the milk sugar being converted into 
fat values. In the adult the ratio of proteid to other food substances 
is as 1 to 5 in the food ; whereas in the infant taking human milk the 
ratio is as 1 to 6, and with cows' milk, 1 to 3. 

According to Rubner, the value of 1 gramme of proteid sub- 
stance of the milk is 4.4 calories, 1 gramme of milk sugar, 3.9 calor- 
ies, and 1 gramme of fat, 9.2 calories. One litre of human milk is 
equal to 650 calories, and 1 litre of cows' milk to 700 calories. An 
infant three months of age, therefore, drinking 800 grammes of 
breast milk would take in 500 calories daily, and if it weighed 5 
kilogrammes it would be taking 100 calories per kilogramme of body- 
weight a day. Bonnoit found by experiment that an infant pro- 
duced 80 calories per kilogramme of body-weight in twenty-four 
hours, and if we deduct 10 per cent, from the raw caloric equivalent 
of the food we would have almost as many calories introduced into 
the body as the body produced. 

The need of 100 calories per kilogramme remains constant during 
the first year of life, diminishes slightly in the second year, with the 
following exceptions : During the first ten days the infant uses up 
only 40 to 50 calories, and the increase of weight is accomplished 
mostly by the watery substances of the food. Rubner and Heubner 
found that of the 100 calories used up by the infant, 20 were util- 
ized to supply body-waste and 80 were burned up to produce heat. 
Therefore the necessary heat-producing calories are much higher in 



METABOLISM IN THE NUBSING INFANT. 87 

the infant as compared to the adult, as are also the number of calories 
necessary to increase body-weight. This greater need on the part 
of the infant is explained by Rubner by the fact that in proportion 
to their body-weight, infants present a greater surface area than do 
adults, and therefore lose much more heat in a given time than adults. 
Therefore the extent of loss of heat is dependent on the extent of 
surface exposed, and allowing for this and not calculating the needs 
of the organism by weight, we find that both the child and the adult 
need the same number of calories. 

The following shows the number of calories produced by the 
various constituents of the food in the adult and in the infant. 

Of 100 calories in the food taken in by the adult, proteids pro- 
duce 19, fats 30, carbohydrates 51. Of 100 calories in the milk 
taken by the infant, proteids produce 18, fat 53, carbohydrates 29. 
In the infant, therefore, the fat is the chief heat producer. It is 
also nitrogen-saving, inasmuch as the latter is used for cell-growth. 

After the first year growth is not so active and less fat is needed, 
and this constituent is replaced by carbohydrates. The following 
table illustrates this : 

Weight- 
Age, kilogrammes. Proteids. Fats. Carbohydrates. 

3 days 3.0 2.4 2.8 2.9 

6 " 3.2 3.7 4.3 4.4 

4 months 6.0 3.8 4.5 4.6 

H years 9.0 4.4 4.0 8.9 

2£ " 10.0 3.6 2.7 15.0 

11 " 23.4 2.8 2.0 11.4 

Adult 70.0 1.7 0.85 7.5 

Mineral Salts. — The infant in its milk takes more mineral salts 
into the body than the adult, kilo for kilo of body-weight. They are 
utilized in the growth of the infant. 

Excreta. — Much is to be learned as to how much should be allowed 
to the excreta in calculating the necessary calories used up by the 
infant organism. By the excreta we mean urea, water, and carbonic 
acid gas. Rubner and Heubner have shown that an infant in the 
first six months excretes less urea than the adult. In the second half 
year the infant excretes more urea than the adult, and this increases 
until the tenth year. In proportion to its weight the infant takes 
more nitrogenous substance into the body than it excretes in the 
form of urea. 

During the first six months, the growth of the infant being most 
active, this is markedly so, and the nitrogen is retained to a greater 
extent in the system during the first six months of infancy. Michael 
has found that the nitrogen excreted in the faeces and urine and the 
proteids of the food retained in the body were one-fourth of the 
whole increase of weight in the newborn infant. 



88 NUTBITION AND INFANT FEEDING. 

Water, — Rubner and Heubner found that of 530 grammes of 
water taken by the ten-weeks-old child into the body, 505.5 grammes 
were excreted, and of this quantity more than half was excreted in 
the form of urine. 

Carbonic Acid Gas (C0 2 ). — Voit, Pettenkofer, Forster, and 
Mensi have shown that from birth to the tenth year of life the child 
excretes one and a half to two and a half times as much carbonic acid 
gas as the adult, and this is practically furnished by the fats. Rubner, 
Heubner, and Bendix, however, have shown that a breast-fed infant 
weighing 5 kilos (11 pounds) exhales per square metre of body- 
surface less C0 2 than the adult. 

Munk thinks that the proteids are utilized in the organism to 
form carbonic acid gas. The principal facts, therefore, adduced in 
regard to the breast-fed infant in connection with metabolism are 
that the infant in the course of the first six months needs for the 
production of warmth, potential energy, and increase of weight 100 
calories per kilo of body-weight. Eighty of these calories are util- 
ized for warmth and energy and 20 for increase of cell-growth. If, 
therefore, an infant takes only 80 calories into its body, its weight 
will remain stationary. If it takes less, it will have to utilize its 
own tissues in order to live, and emaciation will result. 

Metabolism in the Bottle-fed Infant. — What has been said of 
the nursling at the breast applies in a general way to the bottle-fed 
infant, with the exception that Rubner and Heubner have shown that 
an artificially fed infant needs 120 calories instead of 100 per kilo 
of body-weight to maintain warmth, energy, and increase in weight. 
They explain the need of the additional 20 calories taken into its 
body by the bottle-fed infant by the necessity of extra work on the 
part of the intestine in digesting cows' milk. It is of interest that 
the infant, notwithstanding the fact that cows' milk is so entirely 
different in its composition from human milk, can utilize this food 
in the production of caloric energy. The artificially fed infant must 
transform a proteid foreign to the body to one of a nature similar to 
that of human milk. The utilization by the infant of cows' milk is 
not perfect, for we have the following differences between the breast- 
and bottle-fed infant, which are apparent on the surface. 

The increase of weight is irregular in the bottle-fed infant as 
compared to the regular increase in the breast-fed infant. The daily 
fluctuations of temperature in the bottle-fed infant are irregular as 
compared to the fluctuations in the breast-fed infant. The bottle- 
fed infant, as a rule, is an ansemic child; the breast-fed infant the 
contrary. The bottle-fed infant may become rachitic even from 
birth. It is thought to be more susceptible to infection, less resistant 
to the inroads of disease. It is deprived of the enzymes and alexins 



THE FOOD OF TEE INFANT. 89 

present in the human milk. Therefore the metabolic processes in 
the infant fed upon the bottle and those on the breast must necessarily 
differ, and in this respect our scientific data are still incomplete. 
Human milk cannot be completely replaced by any form of animal 
milk. 

THE FOOD OF THE INFANT. 

The study of infant feeding naturally divides itself into the con- 
sideration of the infants fed at the breast by the natural method and 
those fed with some substitute for the breast, such as cows' milk or 
infant foods, or dilutions of the same. 

Human-breast Milk. — Colostrum. — From the third or fourth 
month of pregnancy the human breast begins to show signs of func- 
tionating and secretes a yellowish-white, thick, sticky fluid called 
colostrum. As the period of pregnancy approaches the seventh 
month the secretion of colostrum becomes more active, and its phys- 
ical properties are those of a thin, grayish-yellow fluid which exudes 
from the breast-nipple under slight pressure. 

Physical Properties. — Colostrum differs from the normal milk 
secretion in being of a light-yellowish or grayish-yellow color. It is 
markedly alkaline in reaction. It is rich in fats and proteids, poor 
in casein, in that the albumin exists in relatively greater quantity. 
The composition of the colostrum varies from time to time until the 
period approaches when it is replaced gradually by the normal milk 
secretion. This occurs about twelve days after birth in a normally 
functionating breast. At this time colostrum, as such, should have 
disappeared (Plate V.). 

The average composition of colostrum, according to Camerer and 
Soldner, is as follows: 

Water 86.70 

Proteids 3.07 

Fat 3.34 

Milk sugar 5.27 

Ash 0.40 

It has a specific gravity of 1.040 to 1.060. Microscopically colos- 
trum, in addition to fat-globules, leucocytes, pavement epithelium, 
granules of casein and phosphates, contains the so-called colostrum 
corpuscles and the crescent-shaped bodies of Lourie. The fat-globules 
have similar physical properties to the fat-globules of the milk, and, 
as in human milk, they are found associated with the crescent-shaped 
bodies of Lourie, to be described (Fig. 14). 

The colostrum corpuscle is a spherical body four or the times 
larger than the milk-globule, and measuring \\\ /( to 40 ^ in diameter. 
It contains fat in the granular and globular si ate. The colostrum 



90 NUTRITION AND INFANT FEEDING. 

corpuscle is looked upon by some as a degenerated leucocyte (Czerny). 
The coloring-matter of colostrum is contained in the colostrum cor- 
puscle. These colostrum corpuscles are the distinguishing feature 
of colostrum as compared to milk, and so long as they are present in 
the milk to any appreciable extent it cannot be considered as fit, in 
every sense, for continued infant-feeding. If lactation, for one 
reason or another, is interrupted, the colostrum corpuscles reappear 
in the milk. When lactation is again established these corpuscles 
should disappear from the secretion. Should colostrum persist for 

Fig. 14. 




Colostrum corpuscles and crescents of Lourie. (Marfan.) 

too long a period in the breast, the infant, as a rule, does not thrive. 
It can thus be seen that from the twelfth day or thereabout after 
delivery of the infant, the milk which takes the place of the so-called 
colostrum should contain either no colostrum corpuscles at all or in 
a vanishing quantity. 

In addition to the colostrum corpuscle, colostrum contains an 
interesting crescent-shaped body, described in connection with human 
milk, which is seen adherent to the external border of the fat-globule. 
Some of these colostrum crescents may present an intimation of a 
nucleus. They have been described by Lourie, and can be seen by 
extracting the fat from the colostrum and staining with methylene 
blue or thionine. 

Milk.' — Milk may appear in the breasts the fifth, sixth or tenth 
day after delivery. In exceptional cases I have seen the milk de- 
layed as late as the third week; or it may diminish after having 
appeared and then increase after a few weeks. 

Our knowledge of the chemistry of human milk is still incom- 



THE FOOD OF THE INFANT. 91 

plete and lacking in many essentials which would aid the physician 
in his work. Older analyses of human-breast milk give the gross 
amount of proteids, and Hoppe-Seyler suggested that the casein of 
human milk, or for that matter cows' milk, should be determined 
aside from the total quantity of proteids. Therefore the older analyses 
which deal with the total amount of proteids under the heading of 
casein are not as useful to us to-day as the more modern analyses 
which distinguish between the casein and other proteids in the milk. 
The great importance of this point will become more apparent when 
we study the composition of cows' milk and attempt to modify it to 
conform to the theoretical composition of human milk. 

Composition. — The composition of breast milk varies not only in 
different women and the same woman at various periods of lactation, 
but in the same woman at different times of the day. The result is 
that various analyses differ with each other in a sense, but at the same 
time agree within certain limits. The student can appreciate these 
discrepancies by studying analyses of milk given by a number of 
authors. Whereas there are differences in proteids, these differences 
have certain limitations. 

Konig's analysis, as modified by White and Ladd gives the fol- 
lowing composition of human milk and cows' milk : 

Cow. Human. 

Caseinogen 2.88 0.59 

Whey proteids 0.53 1.25 

&41 L84 

The casein in cows' milk comprises five-sixths of the proteids; 
in human milk, two-sixths of the total amount. We should bear 
this important fact in mind in reading the following tables compiled 
from Camerer and Soldner, showing the composition of human mill: : 

Ether ext. Milk- D * ■ * 

fat. sugar. Proteids. 

Colostrum 5.0 4.5 3.5 

Milk, fifth day 2.3 6.7 1.6 

Milk, ninth day. . 3.4 6.7 1.4 

Milk, first month 2.6 7.3 1.1 

Second and third months 2.4 to 1.9 7.5 0.9 

Backhaus gives the following table of average composition (in 
100 parts) of human milk: 

Water , . 88.20 

Proteids / ° 75 casei "- # 

I 1.00 albumin (whey proteids V 

Fat 3.50 

Sugar 6.20 

Ash 0.25 

On comparing those figures with those o( ICorn'o-, White and 



Sugar. 


Fat. 


4.20- 7.60 


0.70-9.00 


5.90- 7.80 


2.70-4.60 


5.35- 7.95 


1.31-7.61 


5.20-10.90 


1.60-9.46 



92 NUTRITION AND INFANT FEEDING. 

Ladd, it will be seen that White and Ladd include all the proteids 
exclusive of casein under the name of whey proteids. The whey 
proteids are principally lactalbumin and lactoglobulin. 

The above analyses tend to show that one examination of any 
breast milk gives but incomplete information as to its constant quali- 
ties; it will only tell us the composition of that one specimen of 
milk. In a general way we can speak of averages, and these we 
shall try to elucidate under the various headings. In order to appre- 
ciate the wide variations in the percentages of the proteids, sugar, 
and fats present at the different periods of lactation, it is further 
necessary to study the following analyses of leading authorities : 

Proteids. 

Pfeiffer 1.049-3.04 

Johanessen and Wang . . 0.900-1.30 
V. and J. Adriance .... 0.230-2.60 
Schlossmann 0.560-3.40 

Compared with human milk, the following table of animal milk 
is instructive (Konig) : 

Human. Cow. Goat. Ass. 

Water 89.6 87.7 87.3 89.6 

Casein 1.4 3.0 3.0 0.7 

Albumin 0.6 0.4 0.5 16 

Fat 3.1 3.7 3.9 1.6 

Sugar 5.0 4.5 4.4 6.0 

Ash 0.3 0.7 0.8 0.5 

Proteids. — There are four albuminous bodies or proteids in hu- 
man milk. The most important is the casein, which is in a class by 
itself. The other group of proteid bodies includes the soluble albu- 
mins or whey proteids (lactalbumin), globulin, and opalisin. The 
casein of human milk comprises two-sixths of the total amount of 
proteids; whereas in cows' milk it comprises five-sixths of the pro- 
teids. This is an exceedingly important distinction between the two 
milks. The casein of human milk is, according to reaction, a differ- 
ent casein from that of the milk of the lower animals. Szontagh and 
Wrobelewski contend that whereas the casein of human milk does not 
yield pseudonuclein on pepsin digestion, it is not a nucleo-albumin, 
and hence differs widely from the casein of cows' milk. Human 
milk, as stated, is not only poorer in casein than cows' milk, but the 
casein is less in proportionate combination with the remaining pro- 
teids and lactalbumin. This in part explains the more flocculent 
nature of the casein coagulum in human milk. 

The casein of human milk is derived from the protoplasm of 
the cells of the mammary gland. It is set free from the cells of 
the mammary gland in which the fat is formed. In addition to the 
proteids human milk contains lecithin, 0.58 per cent. (Burrow) ; 
iron, 3.52 to 7.21 mg. to the litre (Jolles and Friedjung). 



PLATE V 



FIG. 1 



FIG. 2 




FIG. 3 



FIG. 4 













'- 


>.'7? 














P . 6 


o 


V 


g *^^Hv"" 




" Co 


8 r o 




1^1 


HF 


& a 


o o a 


■ ' 9 


o ^B 


V 


<>'"« 6 







m 


I*? 


° 

06 




* ° 6 ° ■ o 1 

$o ° ° o oB 

CP O °0° 'V^J 


& L ° 


cf 


P 00 2-5° 

.1 w 


9 2 ** 


t ^H 


■L ' v o c *o p 


f*Of 


0,0 O « 






£p c 


°cV 


. ° 


i ^B§ 




k^i : 


5b V j 

o^ 


>0 8 ^ 








oO|^^^ 


















Microscopic Appearance of Woman's Milk. 

Fig. l.-Normal milk, showing the preponderance of medium-sized fat-globules 
Fig. 2.— Poor milk. Preponderance of large fat-globules and a paucity of fat. 
Fig. 3.— Poor milk, a paucity of fat and an almost granular state of the fat- 

globules. 
Fig. 4.— Colostrum of later pregnancy. 

Kips, i, 2 :uul ;> from Fleischman. Kin. t from Marfan. 



THE FOOD OF TEE INFANT. 93 

Fats. — The fat of human milk is contained in the so-called fat- 
globules. On placing a drop of human milk under the microscope, 
the fat-globule is seen as a highly refracting, spherical body. The 
globule varies in measurement from 0.001 mm. to 0.02 mm. in 
diameter (Plate V.), as compared to 0.0016 to 0.01 mm. the size 
of the fat-globule of cows' milk. It is therefore larger than that 
of cows' milk. The fat of human milk is a yellowish-white mass, 
when separated resembling butter, with the specific gravity of 0.9 66. 
It melts at 34° C, and is solid at 20.2° C. It contains butyric, 
caproic, capric, myristic, palmitic, stearic, and oleic acids. It is 
poor in volatile fatty acids. The non-volatile fatty acids consist of 
fully 50 per cent, oleic acid, while the palmitic and myristic acids 
exist in greater quantity than the stearic acid. 

In addition to the casein and fat we have the water, 89.6 per 
cent. Moreover, human milk contains nucleon, 0.124 per cent. ; 
lecithin, 0.58 per cent. ; iron, 3.52 to 7.21 mg. to the litre. 

If milk is stained with carbol thionine or methylene blue there 
are seen, as in the colostrum, crescent-shaped bodies which are adher- 
ent to the outer border of the fat-globule. They are not nucleolar 
or remains of nuclei, but are portions of the mammary epithelium 
which have adhered to the milk-globule at the time of its expulsion 
from the cell (Lourie). 

Mineral Salts in the Milk. — Human milk contains a number of 
salts, among which are calcium phosphates, potassium, magnesium, 
iron, alum, calcium and sodium chlorides, sodium carbonate, traces 
of fluorine and silicium. The most important of these salts are the 
tribasic calcium phosphates, part of which are held in solution, an- 
other part exists in a colloid state, the remaining portion being in 
suspension, and is seen under the microscope as minute dust-like 
particles in the milk, %ooo mm. in diameter (Duclaux). The tri- 
basic calcium phosphate is insoluble in water, but in the milk is held 
in solution by the presence of the alkaline citrates. 

Salts in the milk. Human milk. Cows' milk (Soldner). 

Natrium chloride 1.35 0.962 

Calcium chloride 0.70 0.870 

Calcium phosphate 2.50 1.477 

Natrium phosphate 0.40 

Magnesium phosphate 0.50 0.336 

Carbonate of soda 

Fluorite calcium trace. 

Potassium citrate 0.495 

Magnesium citrate . . 0.867 

Calcium citrate 2.1 33 

Iron phosphate 0.01 

Reaction. — The reaction of human milk depends on the presence 
of the contained salts. It is amphoteric, alkaline to litmus and acid 



94 NUTRITION AND INFANT FEEDING. 

to phenolphthalin. The actual quantity of sodium and potassium 
varies, the sodium being more abundant than the potassium at the 
beginning of lactation (De Lange). In other words, the reaction of 
human milk is amphoteric. 

Specific Gravity.- — The specific gravity ranges from 1.028 to 
1.034, being lower in poorly nourished women. 

Bacteria in the Breast Milk. — A woman in good health will show 
bacteria in the breast milk. They are found in the galactiferous 
ducts of the breast nipple. After expressing the first drops of milk 
and flushing the ducts, it is found that the after-coming milk is free 
from bacteria. The bacteria found in the breast milk belong prin- 
cipally to the Staphylococcus albus class but the Staphylococcus 
pyogenes aureus and some forms of Streptococcus have also been 
found by Kohn and Neuman. 

These bacteria have no ill-effect on the infant, and the attempt to 
trace dyspeptic disturbances to them is not supported by clinical 
facts. 

Enzymes and Alexins of Human Milk. — According to the latest in- 
vestigations, the proteids of human milk contain certain derivatives 
of the living cell. !N"ot much is known about them as yet, but their 
presence proves beyond a doubt that human milk is a substance 
essentially different from the milk of other animals. Moreover, their 
presence in the milk and the presence of other substances in animal 
milk proves that all milk is a living product and not a dead substance. 

The enzymes are the soluble ferments in human milk, the most 
important of which is the so-called amylase, first described by 
Bechamp and subsequently by Moro. It is capable of converting 
starch into sugar in the same manner as does the secretion of the 
parotid gland; in other words, it exerts a diastatic action on starch. 
Amylase is not found either in cows' or sheep's milk. It is destroyed 
by heat, and human milk heated above a certain temperature loses 
its amylolytic properties. This ferment is present, though to a much 
less degree, in dogs' and asses' milk. It is supposed to be derived from 
and is a product of the glandular tissue of the mammary gland, and 
is not primarily present in the blood. The reason of its presence 
in human milk is not quite understood, inasmuch as the infant 
reared exclusively on breast milk does not receive any starchy sub- 
stances in its food. 

Marfan isolated another ferment in the milk, called lipase, which 
is capable of splitting monobutyrin into butyric acid and glycerin. 
This lipase is present to a slight extent in cows' milk. Human 
milk contains also a ferment capable of splitting salol into phenol 
and salicylic acid, and a substance capable of coagulating fibrin, 
inasmuch as a minute quantity of human milk added to hydrocele 



TEE FOOD OF THE INFANT. 95 

fluid causes its immediate coagulation (Moro and Hamburger). This 
substance is not present in cows' or goats' milk. Moreover, human 
milk, as also the milk of animals, possesses certain vital specific 
properties. Bordet, Moro, and others have shown that if human 
milk, cows', goats' or any other animal milk be injected into the 
peritoneal cavity of an animal, the serum of that animal in very 
high dilutions is capable of coagulating the milk of the animal 
whose milk was injected into its body. 

Human milk contains so-called alexins — that is, bactericidal and 
globulicidal substances — and Moro has shown that the serum of the 
blood of the breast-fed infant is more bactericidal than the serum of 
the blood of the infant fed upon cows' milk. 

Amount of Breast Milk Consumed by the Infant in Twenty-four Hours. 
— Camerer has collated and analyzed the results obtained by Ahlfeld, 
PfeifTer, Weigelin, and Hahner as to the quantity of breast milk 
taken daily by an infant. These figures were obtained by weighing 
an infant from the earliest period before and after nursing. Camerer 
gives us the following table, the amounts being indicated in cubic 
centimetres : 

Day. 



1st. 2d. 
30 130 


3d. 4th. 5th. 6th. 7th. 10th. 
240 290 330 365 400 450 

Amount of Milk Taken. 


14th. 
500 


Middle 2d week. 4th week. 7th week. 10th week. 
Minimum ... 210 380 520 600 
Medium . . . 440 580 770 800 
Maximum . . 540 810 1040 1170 


20th Aveek 

700 

900 

1150 



The amount of breast milk consumed by the infant at each nurs- 
ing must vary with the frequency with which the infant is placed at 
the breast. If the infant is placed at the breast five times in twenty- 
four hours the mean quantity of milk taken at each feeding is 
quite large as is seen by consulting Ahlfeld' s figures. Thus an 
infant at the breast 

1 month old consumes 104 coin. 

2 months " " 163 " 

3 " " " 173 " 

4 " " " 212 " 

5 " " " 212 " 

6 " " " 214 " 

n u a u 217 

These figures are within the limits of stomach capacities given 
by Pfaundler and in excess of those of Fleischman, Holt, and Rotch. 

If the infant nurses at more frequent intervals than Ahl fold's baby. 



96 NUTRITION AND INFANT FEEDING. 

the quantity of milk ingested at each nursing will be less than the 
above figures. 

It is noteworthy that on the first day of life the infant observed 
by Camerer nursed three times, and seven times in twenty-four 
hours from the second to the fourteenth day. Each nursing occupied 
a mean of about twenty to twenty-five minutes. These data are of 
value in the artificial feeding of infants. 

The quantity of milk secreted by the human breast may increase 
up to the ninth week of lactation, and remain stationary from this 
time to the period of weaning; or the amount of milk secreted daily 
may increase from the earliest period to that of weaning, when it is 
at its height (Czerny). 

Changes in the Composition of Milk. — Daily Changes. — Milk may 
vary in composition in the course of twenty-four hours in the same 
nurse, both in the total amount of proteids and fats, to the extent of 1 
per cent, or more. Schlichter has found that the changes occur at 
various times in the day. 

The composition of the milk in the nursing woman at different 
hours of the day may be seen in the following table by Schlichter : 

Nurse A. Casein. Fat. Proteids. Sugar. 

Morning 1.10 0.80 1.69 7.11 

Noon 1.10 1.88 2.16 6.92 

Night 3.16 1.95 6.83 

Nurse B. 

Morning 0.55 3.77 1.19 5.37 

Noon 0.77 3.90 1.91 6.15 

Night 0.71 3.73 1.26 6.19 

Nurse C. 

Morning 0.55 3.61 0.19 6.18 

Noon 0.83 4.21 1.08 6.24 

Night 0.41 3.60 1.16 6.47 

Gregor has shown that the variation in the color and consistence 
of the stools of infants can be accounted for by the variation in the 
gross amount of fats in human milk at different times of the day 
and from day to day. 

Influence of Foods on Breast Milk. — A diet rich in nitrogenous 
substances increases the quantity of the milk and the percentage of 
fats and proteids. A diet rich in fat may increase the percentage 
of fat in the milk. On the other hand, it is not always possible 
to increase the casein in the milk by means of diet if the milk is poor 
in this constituent (Konig). Starvation lessens the quantity of the 
milk and the proportion of the casein to the other proteid bodies in 
the milk in the same manner as does a poor dietary (Decaisne). If 
we enlarge the diet we improve the milk. Beer and malt liquors 
increase the quantity of the milk and the percentage of its fat-con- 
stituents (Konig). 



THE FOOD OF THE INFANT. 97 

Iii trying to improve the milk of the human breast we should 
not resort to too much experimentation, for a good milk will some- 
times be made unfit for the infant by placing the nurse or the 
mother on a diet to which she is unaccustomed. On the other hand, 
I have seen the milk retain its colostrum characteristics through the 
fact that the mother did not follow out the dietary to which she was 
accustomed previous to delivery and did not take her usual exer- 
cise. Women accustomed to a wholesome, moderate dietary will, 
if fed liberally with fats and carbohydrates, secrete a milk rich in 
fats and poor in proteids ; such a milk will at once disagree with the 
infant (Konig). 

If a nurse has been on an insufficient diet, the diet should be 
increased in a general way. She should have a moderate allowance 
of meat, partake sparingly or not at all of tea, coffee or beer, and have 
sufficient exercise. If with these changed conditions the milk does not 
improve both in quantity or quality we should not hesitate to replace 
the nurse by another ; or if the mother is nursing the infant, to aid the 
breast with artificial food. This is preferable if the mother is nursing 
to taking the infant away from the breast. 

Drugs and Foreign Substances in the Milk. — Iodine and salicylic 
acid may pass from the blood into the milk of the human breast. 
Iodine may even cause iodism in the nursing infant when the nurse is 
taking any appreciable amount of iodide of potassium (Koplik). 
Iodine is eliminated in combination with the casein of the milk. 
As to the appearance of other substances, such as drugs, in the 
human milk if taken in medicinal doses by the mother or nurse much 
is to be learned, for very little is actually known. 

Opium is not eliminated if taken in ordinary doses, though atro- 
pine may, if taken by the nurse, be eliminated in the milk and cause 
dilatation of the pupil in the infant. Alcohol taken in limited 
amounts, as is customary at the table, is not found as alcohol in 
breast milk; but if larger quantities are taken, from two-tenths to 
six-tenths of 1 per cent, of alcohol may be found in the milk. 

Passage of Bacteria of the Infectious Diseases Into the Breast Milk. 
— The extent to which bacteria of the various diseases may pass into 
the milk of the infected woman is still a matter of question. Under 
the heading, Contra-indications Against Nursing the Infant, this 
matter has been discussed in part. It has been proved that the 
toxins, antitoxins, and agglutinins of the infectious diseases, such as 
typhoid fever and diphtheria, may pass into the milk of the nursing 
woman suffering from these diseases. The bacillary infection of the 
milk, however, is quite a different matter, concerning which much is 
to be learned. In local tuberculous infection of the mammae it can 
well be understood that bacilli may gain direct access to the milk 

7 



98 NUTRITION AND INFANT FEEDING. 

through infectious foci of the galactiferous ducts. It is still question- 
able whether milk from a gland free from local foci, though coming 
from a woman affected with tuberculosis, may contain tubercle bacilli. 
In typhoid fever and diphtheria the bacilli may appear in the milk of 
a woman suffering from severe systemic invasion of the bacilli of 
either of these diseases, but, as a rule, this is not the case. In pneu- 
monia we can scarcely apply to the human subject the results obtained 
in the lower animals, for in the former the disease is rarely an in- 
vasion of the blood to the extent seen in the lower animals. Thus, 
cases such as those published by Bozzolo, in which pneumococci were 
found in the milk of a woman suffering from severe pneumonia and 
endocarditis, are exceptional. 

Toxins, Antitoxins, and Agglutinins. — Tetanus toxins and antitoxins 
may pass into breast milk, and in certain animals, such as mice, this 
milk may confer immunity on the nursling (Ehrlich, Brieger). 

Diphtheria toxin and antitoxin may be eliminated in the breast 
milk. Ehrlich and AVassermann found that goats immunized against 
diphtheria could confer this immunity through the milk. Roux and 
Martin confirmed this observation in the cow. It has also been proved 
that the breast milk of women convalescent from typhoid fever pos- 
sessed agglutinating properties on the Eberth bacillus similar to that 
of the blood (Achard, Bensaude), and that this agglutinating prop- 
erty could be transferred to the blood of the infant nursing this milk 
(Landouzy, Griffon, and Casteigne). In passing from the blood into 
the breast milk the agglutinating substance is much weakened, like- 
wise more so when transferred from the milk to the blood of the 
nursing infant. 

The above facts would seem to indicate that the question as to 
whether the breast milk of a mother or nurse suffering from anv 
disease is fit for the nursling is not an indifferent one. The passage 
of toxins, antitoxins, and agglutinins into the milk should, with reser- 
vations mentioned elsewhere, forbid the use of any breast milk coming 
from a mother or nurse the victim of active acute or chronic disease. 

Menstruation. — The effect of the function of menstruation on 
breast milk is still a matter of discussion. Botch has found some 
variations at this period, not only in the percentage of the fat, but in 
the proteids, from that which existed before menstruation. Other 
authors think the greatest variations will be found in the fats (Ben- 
dix). I am inclined, however, from my own experience to believe 
that variations in breast milk during menstruation are exceptional, 
for the great majority of infants do not show at this time any dis- 
turbances of the functions of the gut. An exception to this may prob- 
ably be the first menstruation of lactation. Infants at this time may 
have green movements and slight colicky pains which persist until 



THE FOOD OF THE INFANT. 99 

menstruation is established in the mother, when all functional disturb- 
ances of the gut disappear and the children do not seem to be dis- 
turbed by the recurrence of the function. In fact, if we study the 
tables of the analyses made before and during menstruation and sub- 
sequent to this period we shall see that the variations are no greater 
than those which occur from day to day when menstruation ia 
absent. 

Pregnancy. — The question is frequently asked, " Has pregnancy 
any effect on the quality or quantity of the milk, and may an infant 
nurse the breast of a pregnant woman ? " Having conducted a 
very large dispensary class in diseases of infancy and childhood for 
fifteen years, I not infrequently saw infants nursed at the breast of 
pregnant mothers. Such infants did not seem to suffer; some of 
them, in fact, being beautiful babies. Examination of these mothers 
showed them to be pregnant from four to six months. The milk 
secretion was not markedly changed in amount. This corresponds 
to what has been established by Poirier, who found that of 100 
pregnant mothers who nursed their infants, 72 infants showed no 
change in their general well-being, while 20 showed disturbances 
necessitating immediate weaning. Eight infants showed slight intes- 
tinal disturbances. The question may be justly asked whether a like 
proportion of cases might not be met with necessitating weaning 
among mothers not pregnant and nursing their babies. Pregnancy 
may diminish the amount of milk, but in the majority of cases no 
change occurs. It is just, however, unless extraordinary indications 
to the contrary exist, that a mother should not be asked to nurse her 
baby while pregnant with another. Such an infant should be weaned 
from the breast. 

Methods of Analysis of Human Milk. — In the section treating 
of the examination of breast milk it was shown that with experience 
it is possible to decide in a general way as to the quality of the milk 
without chemical analysis. Emergencies, however, arise which may 
necessitate more careful examination of the milk in order to account 
for some disturbing symptom in the infant. After thriving for a few 
weeks the infant may, without apparent cause, cease to gain in 
weight, or the movements may be abnormal, or there may be colic. 
Under these conditions it is certainly an advantage to be able to de- 
termine the composition of the milk, since a chemist is not alwavs at 
hand. Conrad, a physician in Bern, has devised some instruments 
which are easily manipulated and are within the reach o( every 
physician. His article, published in 1880, is still unsurpassed in 
clearness of detail. The milk (o be used in all analyses is thai ob- 
tained in the mid-period of nursing. 

Specific Gravity. —To ascertain the specific gravity, Conrad re- 



100 



NU TBI HON AND INFANT FEEDING. 



I C. ■■■jjilli 

AeiW 



-IP 

m! 

lift 
I 

I I 



Fig. 



Fig - 15 - duced the size of Quevenne's lacto- 

densimeter so that it could be uti- 
lized for taking the specific gravity 
of small quantities of mother's milk 
(Fig. 16). The specific gravity is 
taken at 1.5° C. The scale runs 
from 1020 to 1050. 

Fat. — Conrad estimated the fat 
by first calculating the cream layer. 
This he determined by means of a 
graduated glass cylinder devised by 
Bouchardat, Quevenne, and Cheva- 
lier. This cylinder he reduced in 
size. The method is so unreliable 
that it is merely mentioned in pass- 
ing. 

Of greater reliability is the 
Marchand tube, reduced in size by 
Conrad. The set consists of two 
of these tubes. Each tube analyzes 
5 c.c. of milk (Fig. 15). 

Five c.c. of milk are poured into 
the tube, and then 5 c.c. of ether. 
These are well shaken after a drop 
of officinal caustic soda solution has 
been added. Absolute alcohol is 
then added up to the A mark. The 
whole is again shaken and placed in 
water at 35° to 40° C. for ten or 
fifteen minutes. The fat separates 
above, and is read off. A percentage 
table accompanies the instrument. 
This instrument is not accurate. 
There is a variation of from 0.2 to 
0.5 per cent, or more. Two analy- 
ses are made at the same time for 
the sake of accuracy ; hence the two 
tubes. 

Lewi's Method. — More accurate 
than Conrad's is the method worked 
out in my clinic by Lewi. This is 
really an adaptation to breast milk 
of the Babcock sulphuric acid 
method, as modified by LefTman and Beam. 

The apparatus needed comprises a reduced Babcock bottle, a 



Conrad's lactobutyr- 
onieter. 



Conrad's lactoden- 
simeter. 



TEE FOOD OF TEE INFANT. 



101 



Fig. i: 



2.92 



pipette for measuring the milk and acid, and a smaller 1 c.c. pipette 
accurately divided into cubic 
millimetres (see Figs. 17, 
18, 19). 

The pipette is filled to 
the meniscus (this represents 
2.92 c.c. of mother's milk) 
and introduced carefully into Fig. 18. Fig. 19. 

the body of the bottle, so that 
the long thin pipette comes 
down into the body of the bot- 
tle. The pipette is cleansed, 
and refilled to the meniscus 
with chemically pure sul- 
phuric acid ; the pipette is in- 
troduced as before. This pre- 
caution is taken in inserting 
the pipette so that at this 
stage no ebullition shall occur 
in the neck of the bottle, and 
so invalidate the result. 
Next, fill the 1 c.c, pipette 
up to the sixth marking with 
a mixture of equal parts of 
fusel oil and concentrated 
hydrochloric acid; add this 
to the milk and sulphuric 
acid and fill the bottle with 
equal parts of sulphuric acid 
and water. The bottle is 
placed in an aluminum re- 
ceiver and adjusted to the 
centrifuge. The specimens 
are revolved one and a half 
to two minutes, and the read- 
ing is then taken. 

This method, if carefully 
carried out, gives very little 
error, and is practically equal 
to the Soxhlet quantitative 
fat estimation. It can be ap- 
plied to cows' as well as to 
human milk. 

The following table shows the error in the various methods a- 
compared with accurate chemical determination: 



v» 



j 

Instruments employed in the estimation of 
Cat in milk. Lewi's method. 



, 



102 



NUTRITION AND INFANT FEEDING. 



1 

Soxhlet 
(chemical). 


Reduced 
centrifuge. 


Marchand. 


Feser. 


Spec 


men 1 4.4 per cent. 


4.4 per cent. 


3.48 per cent. 


5.00 per cent. 




II. . 






2.4 


2.3 


2.56 


2.37 " 




III. 






1.1 


1.1 


1.44 


1.25 " 




IV. 






3.9 " 


3.8 


3.17 


3.25 




VI. 






4.6 


4.7 


2.35 " 


3.80 




VII. 






2.3 


2.3 


3.99 


2.20 " 




VII. 






4.4 


4.2 " 


3.68 


4.20 " 




VIII. 


4.7 


4.6 " 




3.60 " 



The Proteids. — To possess clinical value in the determination of 
the proteids, a method must differentiate between the amount of 
casein and that of the other proteids, such as lactalbumin and lacto- 
giobulin. This is possible only by careful and exhaustive quanti- 
tative chemical analyses. The methods . at our disposal which are 
practicable in the physician's office determine only the gross proteids. 
The gross proteids may be normal in amount, and the casein or 
caseinogen be deficient. Such milk would not be nutritious. This 
was demonstrated years ago in sick and starving women (Decaisne). 

The following is the method of Woodward for determining the 
total proteids: Two "milk burettes" (Fig. 20), each containing 

Fig. 20. 




Milk burette of Woodward. 



5 c.c. of milk, are allowed to stand overnight in a warm place (100° 
F., 38° C). They are then cooled. The milk is drawn off into 
two Eshbach tubes, and 10 c.c. of the Esbach solution added. The 
tubes are then shaken, put into a centrifuge, and rotated until the 
reading is constant. This method was perfected in the Pepper 
Laboratory, Philadelphia. The author has utilized this method, and 
found it satisfactory. 

Cows' Milk. — Composition. — Of 700 analyses, Konig gives the 
following as the average composition of cows' milk for 100 parts: 
Water, 87.2; casein, 2.88; albumin (lactalbumin), 0.51; fat, 3.68; 
sugar, 4.90. Cows' milk has a specific gravity of from 1.028 to 
1.034. It is amphoteric in reaction, but is relatively more acid than 
human milk. Fresh cows' milk does not coagulate on boiling, but heat 
causes a skin of casein and lime salts to form on the surface of the 
milk. If allowed to stand at the temperature of the room, lactic acid 



TEE FOOD OF TEE INFANT. 103 

is formed in cows' milk as a result of bacterial growth and splitting 
of the- milk sugar and coagulation or curdling of the casein occurs 
when the milk is heated ; after a while, an excess of acid being formed, 
spontaneous separation of the casein will occur. 

Fat. — JFat is contained in cows' milk, as in human milk, in the 
form of fat-globules, which are held in suspension in the serous part 
of the milk by an envelope of albumin. There is no doubt that the 
milk-globules contain all the fat of the milk. The fat-globules are 
smaller than those of human milk. It is uncertain whether the fat- 
globules contain any protein substances. 

Proteids. — The casein of cows' milk is a nucleo-albumin, con- 
tains phosphorus and coagulates when heated, as also by the addition 
of acids and rennet. The amount of casein in cows' milk is not 
only relatively but absolutely greater than in human milk; and in 
describing human milk it was stated that the casein forms five- 
sixths of the total proteids in the cows' milk; whereas in human 
milk the casein forms two-sixths of the total proteids. This one 
fact is of far-reaching importance. 

Simple dilutions of cows' milk still leave it with a greater propor- 
tion of casein, as compared to the other proteids in the milk, than 
that which exists in human milk. Though we may dilute cows' 
milk so as to reduce the proteids to the relative proportion in which 
they exist in human milk, we cannot do this without at the same time 
reducing its nutritive value ; that is, we fail to get the quantity of 
digestible proteids in the milk, although the proteids may exist in the 
same proportion in our mixture. In other words, the proteids of the 
cows' milk are not so completely assimilated by the infant as are those 
of human milk. Again, the casein of cows' milk is precipitated or 
coagulates very early with the aid of acid and salts ; that of human 
milk quite late or not at all. In the human stomach, therefore, cows' 
milk will not take up as much acid of the gastric juice without coagu- 
lating as will human milk and the coagula occur in large masses. AYe 
can readily see in this another disadvantage in the use of cows' milk 
as an infant food. Human milk, on the other hand, takes up a 1 arize 
amount of the acid of the gastric juice and coagulates in very tine 
flocculi. This finer mode of coagulation accounts partly for the more 
complete assimilation of human milk by the infant. 

It was formerly thought that the casein of human and cows' 
milk were chemically identical. Later study, however, shows that 
the casein of human milk, in contradistinction to that of cows' milk, 
is not a nucleo-albumin (Szontagh). Human milk is richer in 
nucleoli and lecithin than cows' milk and contains more combined 
phosphorus than cows' milk in the nucleoli. It can be seen from 
this that the contention o( Hoppe-Seyler, Hammarsten. ami Wrobe- 



104 NUTBITION AND INFANT FEEDING. 



lewski, that the two caseins are essentially different, is well founded. 
Xot only is the casein of cows' milk a substance sui generis, but its 
digestion in the intestine of the infant is accomplished with great loss. 
Moreover, it has been shown that the salts of cows' milk, especially 
those of lime and potassium, are not well assimilated by the infant 
gut, fully 34 per cent, of these salts being excreted by the put; 
whereas only 10 per cent, of these salts are found in the faeces of the 
infant fed at the breast. 

These facts are of great importance in comparing the two modes of 
feeding infants — that of the breast and the bottle. The prevalence 
of bone disturbances of the severer type in artificially fed infants is 
thus partly explained by the loss of the salts of lime and potassium, 
these being important to bone nutrition and growth. The increase 
of weight in artificially fed infants also gives us an insight into the 
physiological processes in such infants. The quantity of milk, as 
before stated, necessary to maintain nutrition is greater in the case 
of the bottle-fed infant than in that fed on the breast. There is always 
a danger of overfeeding an infant which is bottle-fed. The increase 
of weight is not as regular in the bottle-fed infant as it is in the 
breast-fed infant. 

The following will show at a glance the differences in the assimila- 
tion of the various elements of cows' milk as compared to human 
milk by the infant gut (Uffelmann) : 

Cows' Milk Human Milk. 

Proteids 98.7 per cent. 99.5 per cent. 

Fats 93.5 " 97.5 

Salts 66.2 " 90.0 

Sugar 100.0 " 100.0 

Ash 92.0 " 97.0 

According to Forster, an infant four months of age taking 1215 
c.c. of cows' milk excreted three-fourths of the lime salts in the faeces. 

Bacteria in Cows' Milk. — Pasteurization; Sterilization. — By in- 
sisting on strict cleanliness of the cows' udder, the hands of the 
milkman, and the utensil in which the milk is collected, it is pos- 
sible to obtain a milk tolerably free from bacteria. In commerce, 
however, this is manifestly impracticable. Milk collected with the 
greatest care contains bacteria, and if these appear to the extent of 
only 9000 to the cubic centimetre at the time of milking, enough 
will have developed under favorable conditions to cause such an 
increase within twenty-four hours at an ordinary temperature as to 
bring this number up to 5,600,000 to the cubic centimetre (Miquel). 
Soxhlet has shown that in order to inhibit the growth of these bac- 
teria in the milk, it must be kept at a very low temperature, and in 
summer weather practically in contact with ice. 



THE FOOD OF THE INFANT. 105 

The most important bacteria found in milk are the Bacterium 
lactis aerogenes, the Bacillus mesentericus vulgatus (the potato ba- 
cillus), and the Bacillus subtilis. (Jews' milk may contain also 
streptococci which come from the udder of the animal, and any 
pathogenic bacteria, such as the pneumococcus, typhoid bacillus, 
diphtheria bacillus, the germs of scarlet fever, measles, or tubercu- 
losis, cows' milk being an excellent culture medium for the growth 
of germs of all infectious disease. 

The habitat of the bacteria of cows' milk is first the teat of the 
udder. The milk ducts in the teats are of considerable size and 
residual milk decomposes in them. The entrance of bacteria into 
these ducts, such as the Bacterium lactis aerogenes, the hay bacillus, 
the potato bacillus (Bacillus mesentericus vulgatus), is favored by 
the habits of the animal and uncleanliness in the stalls in which the 
animal is kept. Uncleanly utensils in which the milk is collected 
are a source of contamination. 

Infected Cows' Milk as a Cause of Epidemics. — Typhoid Fever. — 
Cows' milk is unquestionably an excellent medium for the growth 
of bacteria and is most readily infected ; thus, epidemics of typhoid 
fever have been traced to infected milk. Such milk becomes infected 
either in the dairy, where the fever may be prevalent among the dairy- 
men, or through dairy utensils which have been cleansed with in- 
fected water. 

Dysentery. — Dysentery may be caused by drinking infected milk 
(Klein). 

Diphtheria. — The Klebs-Loffler bacillus grows quite well in cows' 
milk, which may consequently be the means of readily spreading the 
disease ; thus, school epidemics have been traced to infected milk. 

Scarlet Ftsver. — Scarlet fever has been conveyed by cows' milk 
infected by those contaminated with the disease (Kober, Freeman). 

Cholera Asiatica. — Cholera Asiatica may be conveyed through 
milk diluted with infected water or milk handled by a cholera- 
infected individual. 

Tuberculosis. — It is not the place here to discuss the transmission 
of tuberculosis to the human subject by means of the milk of a 
tuberculous cow. This matter is secondary to the more immediate 
question as to the prevalence of tuberculosis in the infant and child 
as a result of the ingestion of infected cows' milk. That this mode 
of acquiring tuberculosis is exceedingly rare will be acceded to by 
most observers, and published epidemics or isolated cases o\' tuber- 
culosis in children, caused by infected cows' milk, lack the evidences 
of absolute certainty as to etiology. 

Aside from tuberculosis, it is generally granted thai suppurative 
disease of the udder of the cow may cause serious digestive disturb- 



106 NUTRITION AND INFANT FEEDING. 

ances in the infant by infecting the milk. In fact, certain forms 
of stomatitis are traced by some (Forcheimer) to such a source. 

Milk Acidity. — If milk is not cooled immediately after milking, 
and kept cool, it soon shows a marked increase in acid reaction. 
This is due to the growth of the Bacterium lactis aerogenes, which 
not only turns the milk acid, but in doing so produces toxins which 
are of considerable danger when introduced into the stomach and 
gut of the nursing infant. Without entering further into details, 
we may say that cows' milk intended for infant-feeding should be 
obtained from a herd of healthy animals, preferably of the Holstein 
type. Mixed milk is to be preferred to the milk from one cow, for 
the reason that any infectious element introduced into the milk coming 
from a large herd of animals is so diluted as to be less dangerous to 
the individual infant than the milk containing infectious matter 
coming in a concentrated form from one animal. 

The milk should be carefully collected in utensils which have 
been thoroughly cleansed and sterilized with steam. The infant 
should obtain the milk as soon as possible after the milking; cer- 
tainly within twenty-four hours. Having been modified and put 
up for the infant's use, the food should be presented to the infant in 
divided portions, each of which is sufficient for a nursing. 

In large cities, where the milk does not come direct from the 
dairy to the infant, it is still thought advisable to subject the milk 
to various forms of sterilization or heating, in order that the con- 
tained bacteria may, for the most part, be destroyed, and that it 
may remain fit for feeding the infant for fully twenty-four hours. 
In places where the milk can be obtained direct from the dairy, and 
where we are certain that the collection of the milk has been carried 
out with care, we may do away with the heating process, especially in 
the winter time. In the summer, however, some form of sterilization 
is necessary. 

Under the term sterilization the author includes both Pasteuriza- 
tion and sterilization. 

Pasteurization. — Pasteurization is to-day the process most in vogue 
for the preservation of infant food, and also to destroy, for the most 
part, any deleterious bacteria contained in the milk. It was first per- 
fected by Pasteur, and therefore bears his name. The milk is sub- 
jected, in a suitable apparatus, to a temperature of 65° C. (149° P.) 
for a variable length of time, generally half an hour, and then rapidly 
cooled to 20° C. (68° F.). The most practical apparatus for this 
purpose was devised by Freeman, and is sold in the shops as the 
Freeman Pasteurizer (Fig. 21). If properly carried out with this 
apparatus, the method destroys all pathogenic germs which may be 
present in the milk, and also a large percentage of the other bacteria 



THE FOOD OF THE INFANT. 



107 



of the milk, including most of the Bacterium lactis aerogenes, but 
does not destroy any sporulated bacteria, such as the Bacillus mesen- 
tericus yulgatus. 

Sterilization. — Sterilization is the process of heating milk to 212° 
F., or 100° C. This may be done by means of the Arnold Steam 
Sterilizer (Fig. 23), or by simply placing the milk in properly corked 
bottles in boiling water. As a rule, the milk is heated for twenty 
minutes, when it is considered sterilized. The milk should then be 
rapidly cooled, as in the process of Pasteurization, for by this process 
the fat of the milk will not separate. Sterilization is best performed 
by the above processes, but the ordinary sterilizers will not render the 



Fig. 21. 



Fig. 22. 



Fig. 23. 




Freeman Pasteurizer 



Arnold Steam Sterilizer. 



milk absolutely sterile. It will not destroy any sporulated bacteria, 
but will destroy the Bacterium lactis aerogenes and all pathogenic 
germs. Milk which contains sporulated bacteria, such as the potato 
bacillus (Bacillus mesentericus vulgatus), may after a short time 
undergo a change due to the proliferation and action of the sporulated 
bacteria, which have not been destroyed by sterilization under ordi- 
nary atmospheric pressure. This consists in a splitting up of the 
casein and a so-called peptonization of the milk. This change begins 
after a few days, and when complete venders the milk alkaline in 
reaction and sweetish in taste. Milk, unless it has been sterilized 
under two atmospheres of pressure and at a temperature above that 
obtainable in the household sterilizer, is never completely sterile. 
Milk which has undergone the above peptonization is unlit for 
infant-feeding. 

Disadvantages of Sterilization as Compared with Pasteurization. - 
Tn describing sterilization and Pasteurization o\' milk, it has been 



108 NUTBITION AND INFANT FEEDING. 

intimated that sterilization has its disadvantages, and these are, in 
short, that the lactalbnmin of the milk is coagulated to a slight degree ; 
the casein is changed, so that it is not as absorbable; the fats are 
liquefied, so that in sterilized mixtures they may be seen on the sur- 
face in the form of an oily layer ; and the lime salts are converted into 
unabsorbable compounds, so that infants taking sterilized milk lose 
these salts for the economy. They do not get the necessary bone 
pabulum. This would account in part, if true, for the prevalence of 
scurvy in infants who take sterilized milk as an exclusive food for 
too long a period of time (Cronheim and Midler ). 

Though sterilization was at first a great step in advance, in- 
asmuch as the process presented to the nursing infant the possi- 
bility of obtaining its food in a wholesome condition hours after its 
preparation, even in the hottest weather, there developed certain 
disadvantages in connection with its prolonged use. It has been 
noted, partly owing to the increased use of sterilized milk and partly 
to the fact that bottle-feeding has become much more general to-day 
than formerly, that infants who take sterilized milk to a certain 
extent do not thrive as well as infants who obtain either a mixed 
diet or a food not so thoroughly cooked. The result has been a de- 
cided increase in the number of scurvy cases, undoubtedly due to the 
changes in the food. Aside from the danger of scurvy, a certain 
proportion of infants who do not develop scurvy and who are fed 
exclusively on sterilized milk remain stationary in weight, although 
the stools of such infants may be normal in appearance. 

Again, infants who are taking sterilized milk develop in a certain 
proportion of cases inordinate constipation, and this in itself is a 
very troublesome feature. In looking for another method of preserv- 
ing the infant food, at least here in America, Pasteurization was 
next taken up. It was found, however, that the heating of the 
lact albumin even to a temperature of 70° C. had its disadvantages, in 
that a certain amount of lactalbumin was coagulated. Still, the dis- 
advantages of Pasteurization are less, as compared to those of sterili- 
zation, and it was at once apparent that if Pasteurization could be 
applied as a method of preservation of infant food, it would be a step 
in advance. The author at first advocated the heating of milk for 
infant-feeding at a lower temperature, a temperature subsequently 
taken up by Monti, of Vienna, of 180° F. At this temperature milk 
will keep twenty-four hours even in warm weather, with ordinary 
care, without turning sour. Even this temperature was found exces- 
sive, and Freeman advocated a still lower one for Pasteurization, and 
devised an instrument for carrying out this process, which to-day is 
in general use. 

Coincident with the agitation against sterilization, and even Pas- 



THE FOOD OF THE INFANT. 109 

teurization of milk, the dairy methods have been so improved to-day 
that the time of Pasteurization can be reduced, and in midwinter, in 
large cities, the milk can be obtained in such purity as to be given raw 
to the infant. The whole question, therefore, of the preservation of 
milk has resolved itself into obtaining a milk as free from impurities 
and as recently from the dairy as possible. Thus, if we are certain 
of the cleanliness of our milk and the care with which it is handled, 
Pasteurization can be followed out as a method of preservation of 
the infant's food, even in the summer time ; but such Pasteurized 
milk, no matter how clean the original milk when received from the 
dairy, must be kept carefully on ice in order to prevent its turning 
sour. Among the poor in large cities, however, Pasteurization is not 
safe in midsummer, and where large numbers of infants are fed from 
laboratories careful sterilization offers the best safeguard against in- 
fantile summer diarrhoea. In the fall and winter, Pasteurization, in 
large cities, is quite sufficient to preserve the infant food ; and, as has 
been stated, in winter we may even, if we are sure of the source of 
our milk and its recency from the dairy, give raw milk to infants. 
Sterilization and Pasteurization, therefore, are simply methods of 
preservation of infant food, and have nothing intrinsic in themselves 
as regards the problems connected with infant-feeding. 

Experimental Study of the Assimilation of Sterilized, Pasteurized 

and Raiv Milk. 

Nitrogen taken Nitrogen remaining 

in milk. in feces. 

Grammes. Per cent. 
First infant — 

Pasteurized milk 10.9209 4.6 

Sterilized milk 13.7449 4.9 

Kaw milk 5.3914 3.4 

Second infant — 

Boiled milk 32.643 4.5 

Sterilized milk . ....... 30.969 4.3 

The table given above shows the comparative digestibility of raw, 
Pasteurized, and sterilized milk (Koplik), as indicated by the per- 
centage of nitrogen remaining in the faeces of the infant. These 
experiments were performed by feeding the same infant with raw 
and heated milk. The results showed that, although the differences 
are slight, they are in favor of milk subjected to little or no heat. 
Doane and Price have confirmed these results by experiments on 
the calf. 

What Shall the Practitioner do in Regard to Sterilization and Pasteuri- 
zation? — If the patient has access to a milk which is only twelve 
hours from the dairy we may simply Pasteurize this milk both sum- 
mer and winter, and in the summer-time L1 should bo carefully kept 
on ice. During the winter we may give such a milk raw it' obtained 



110 NUTRITION AND INFANT FEEDING. 

from a mixed herd of cattle. Raw milk from a limited herd is dan- 
gerous, inasmuch as the dilution is not great enough to eliminate 
impurities from sick cows, should there be such, in a small herd. 
The practitioner should therefore advocate a mixed milk from a large 
herd as the best safeguard against infection of the infant. The 
dairy should be kept scrupulously clean, as should also the animals, 
and the milk kept in clean utensils, in order that the above ideas may 
prove beneficial to infants. If the infant's milk (modified) is to be 
carried any distance during the summer, sterilization is a safeguard 
for a short period of time. 

Raw Milk in Infant-Feeding. — With the improved methods of 
dairy hygiene and care exercised in most cities in the collection of 
milk intended for infant-feeding, the milk contains less bacteria and 
reaches the infant much earlier to-day than formerly. The result 
of this, at least in JNew York, where it is possible to obtain milk 
within twelve to twenty-four hours of the milking-time, has been that 
the milk is of a very low acidity and bacterial content. The ques- 
tion arises whether we may not give such milk, modified properly, 
in a raw state to the infant. For even Pasteurization, it must be 
admitted, tends to change the ingredients of the milk to such an 
extent as to compromise their nutritive value. 

The author in practice Pasteurizes the infant's milk in the winter- 
time, and in many cases gives the milk in the raw state. In the 
summer, however, in large cities, where the icing of milk may have 
been imperfect, it is safest to sterilize the milk during the heated 
term. This is only for a period, at most, of three months. An 
infant taking sterilized milk under proper conditions during the 
heated term is not injured by such a food, and is protected from an 
attack of gastro-enteritis, for it is not possible, even though gr*eat 
care be exercised, to prevent an occasional bottle of milk from in- 
creasing in acidity. The result of such a change might be an attack 
of diarrhoea which would endanger life. In the fall, winter, and 
early spring the practitioner, if he is certain the milk is of good 
quality and has been collected in a careful and cleanly maimer, need 
not do more than Pasteurize the milk. If he is absolutely certain of 
the source and freshness of the milk he may even give it raw. There 
are certain infants who have an idiosyncrasy against the taking of 
raw milk. The acidity cannot be rectified by lime-water, and the 
result is that such infants will have loose movements or even diar- 
rhoea. These cases are exceptional, of course, but they must be borne 
in mind. In exceptional cases the author has seen even Pasteurized 
milk disagree in the same manner with the infant. 

Moreover, we know now that the administration of heated milk, 
especially sterilized milk, over too long a period will cause bone dis- 



THE FOOD OF THE INFANT 



111 



Fig. 24. 



turbances, and it is certainly unwise to give, at least at the present 
day, sterilized milk to infants in the cooler seasons of the year. Even 
with the administration of Pasteurized milk for any length of time, 
it is well at about the fourth to the sixth month of infancy to \Lw<t 
several times daily a small quantity of diluted orange-juice. In this 
way the ill effects of heated milk are counteracted, and the infant is 
supplied with those salts and acids which are lacking in the Pasteur- 
ized and sterilized fluid. 

Frozen Milk.- — The process of freezing is deleterious to cow-/ 
milk, inasmuch as it breaks up the original fat-emulsion, and milk 
when thawed does not present the normal appearance under the micro- 
scope. The individual fat-globules are seen to be angular, and in- 
stead of presenting a spherical refracting body, the globule presents 
concentric rings, showing that in some way the cold has acted on the 
fat. Such milk, if given to an infant, will at times disagree and 
cause greenish diarrhoeal movements, sometimes vomiting. More- 
over, in midwinter it is very common' for children who have pre- 
viously been quite regular in their bowel evacuations, with movements 
of normal consistence and appearance, to become constipated as a 
result of the ingestion of milk which has been frozen 
and then thawed. It seems that the fat of the milk 
undergoes some change which interferes with its 
hitherto cathartic action on the bowels. As a result, 
these infants will have hard, constipated movements ; 
or the movements may be partly constipated or partly 
of normal consistence. In such cases the physician 
will have no other resource but to advise patience 
until the milk can be delivered in an unfrozen condi- 
tion. 

Nursing Bottle. —The best form of bottle is the 
so-called Freeman bottle (Fig. 24), which has very 
little neck, a wide mouth, not much shoulder to the 
neck, so that it may be easily cleansed. For newborn 
infants there is now constructed a very small bottle 
of the same model with a capacity of three ounces, 
the idea being that when milk is given in a small 
bottle, the heat is retained during nursing much better than when a 
small quantity of milk is contained in a large bottle. In the latter 
case the milk is chilled before the termination of the feeding. When 
filled the bottles are corked with non-absorben1 cotton. They are 
corked loosely, so that the steam may escape. If the cotton is jammed 
lightly into the bottle, the cork will blow out in the heating. After 
nursing, the bottles are filled with a solution of washing soda and 
allowed to stand a few hours, and then washed externally and mter- 




Nursing bottle 
of the Freeman 

model. 



112 NUTRITION AND INFANT FEEDING. 

nally and drained dry. Any residue of milk remaining after nursing 
should not be utilized for another nursing. 

The cleansing of the bottle is carried out with a so-called bottle 
brush, tipples should be boiled once daily for ten minutes, and 
washed with hot water after each nursing. It is well to have several 
nipples carefully sterilized in the early morning and kept in a clean 
jar, rather than in a solution of boric acid. If the nipples are kept 
in boric acid the latter is apt to become contaminated, as also the 
nipples. 

Before feeding, the bottle of milk is warmed to a temperature of 
about 100° to 105° F. (40.5° C), so that the milk may not chill 
the stomach of the infant and thereby suspend the digestive process. 
Dr. Sobel has constructed a bottle-warmer, by means of which the 
milk may be heated to exactly the same temperature at every nurs- 
ing. This is sold under the inventor's name in the shops. 

FOOD PREPARATIONS. 

Peptonized Milk. — With the perfection of our methods of the 
modifications of cows' milk, either in the laboratory or at home, the 
use of peptonizing agents as an aid to digestion of the casein of the 
milk has become more and more limited. On the other hand, it 
cannot be denied that the addition of peptonizing substances in safe 
quantities to the milk intended for the infant has a great advantage 
in certain cases of difficult casein digestion. As a rule, the infant 
will not take kindly to completely peptonized milk. It has a bitter 
taste, which cannot be overcome by the addition of sugar or any 
other agent to the milk. We are thus compelled, at least in the 
author's experience, to introduce the peptonizing agent into the milk 
in such a manner as not to change the taste of the food. The best 
method, therefore, of peptonizing the milk for infant-feeding is the 
so-called cold method. This is done as follows : The milk is modi- 
fied, either at home or in the laboratory, in the ordinary way. Just 
before giving to the infant, if the amount is from four to six ounces 
at each feeding, one-fifth of a peptonizing tube is added to the mix- 
ture, which is then well shaken and placed in lukewarm water for 
two and a half minutes, and then given to the infant. Such a milk 
will not have a perceptibly bitter taste. 

Another method of peptonizing milk for infant-feeding is to 
employ the so-called peptogenic milk powder for this purpose sold 
in the shops. A bottle of modified milk containing four or eight 
ounces of the mixture is fortified with about an eighth of a measure 
of peptogenic milk powder just before feeding, heated for seven 
minutes in lukewarm water, and then s;iven to the infant. Infants 



FOOD PREPARATIONS. 1 1 3 

may be kept on this food for months, and then when the digestion 
and powers of assimilation have improved, the peptonization may 
be gradually omitted. The author has seen no ill effects from this 
method of giving peptonized foods. He feels, however, that at various 
intervals during the feeding of such infants, attempts should be made 
to omit the peptonizing ingredients from the mixture, in order to 
see whether the infant cannot thrive without them. 

The indications for the use of peptonizing infant food will be 
given under the heading of Difficult Digestion. 

Condensed Milk. — Condensed milk is very frequently employed 
to feed infants through the whole of the nursing period, and while 
it cannot be denied that some good results are thus obtained, con- 
densed milk, pure and simple, for the majority of infants is not 
available. Many infants will cease to increase in weight under its 
continued use; others will develop rachitis and scurvy. 

Condensed milk is sold in the shops in hermetically sealed cans, 
with or without the addition of sugar. The sugar is used to pre- 
serve the milk, and is generally cane-sugar. Condensed milk is poor 
in fats, although with the dilutions customary in infant-feeding, the 
proteids are not only low, but are in a more absorbable state than in 
most infant foods. Condensed milk also contains a very large pro- 
portion of sugar, both milk- and cane-sugar, and this, as has been 
pointed out under the heading of Nutrition, is one of the most easily 
absorbable foods for the infant. 

An infant successfully fed on condensed milk will show a large 
deposit of fat. It may have a very good color, but a critical eye will 
invariably discover evidences of faulty metabolism, such as rachitis. 
Condensed milk is sometimes of great value in cases of gastro- 
enteritis, in which the digestion of ordinary modifications of cows' 
milk seem to be unsuccessful. It should only be used, however, in 
these cases to tide over a critical period. Condensed milk may be 
used fortified with cream, and under such conditions the cream is 
well assimilated. In traveling, also, if good milk is not available, 
infants who have been fed on carefully prepared mixtures may tide 
over a period of a few days on dilutions of condensed milk. 

The following composition of condensed milk is given by Konig : 

Water. Proteid. Fat, Sugar. Ash. J 

Condensed milk without ) fl1 i fi , , ,- -, i < > -■ .>,*,. i ,>,\ 

cane-sugar |\ 6L46 1L1 ' UA ~ 13 ' 96 l " 

With the ^addition of cane-| 2644 104? ]00 _ 

sugar oiS.bo per cent. • j 

In order to prepare condensed milk for infant-feeding, the milk 
is diluted ten to twelve times for infants below three months of age. 



114 NUTRITION AND INFANT FEEDING. 

and five to six times for older infants. In the cases of gastro-enteritic 
disturbance above mentioned, when the assimilation of cows' milk is 
difficult in the period following subsidence of symptoms, dilutions 
of condensed milk, with the cautious addition of raw cream or top 
milk, are borne better than modifications of cows' milk. This method 
of feeding should be resorted to only after a demonstration of the 
failure of milk modifications, and should only be preliminary to 
feeding with fresh cows' milk. 

Barley-water. — Barley-water is one of the most useful adjuvants 
either to modified milk mixtures or as an exclusive food for a short 
time in cases of gastro-enteritic disturbances. The proper preparation 
of barley-water has been the subject of much study. The simplest 
method of preparing barley-water is that which utilizes the so-called 
Robinson's Patent Barley. A heaping teaspoonful of Robinson's 
Patent Barley is suspended in a pint of cold water until the lumps 
have disappeared. The mixture is then placed in a small saucepan 
over a gas-stove fire, and stirred constantly for fifteen to twenty min- 
utes while boiling. The more the barley-water is boiled, the more 
thoroughly the barley is dissolved and dextrinized. After boiling, the 
loss of bulk is made up to the original quantity by the addition of 
water. The use of the so-called dextrinized barley instead of Robin- 
son's Patent Barley offers in certain cases advantages to which refer- 
ence will be made later on. Dextrinized barley is sold in the shops 
as such. It is made up of barley-pearls ground and heated for a long 
period of time according to the formula of J. Lewis Smith. The 
composition of Robinson's Patent Barley is given by Konig as 
follows : 

Water 10.10 

Proteids 5.13 

Fats 0.97 

N.-free extractives (carbohydrates) 81.87 

Ash * 1.93 

It will be seen by a study of its composition that carbohydrates 
enter into it very largely. Fats and proteids are present in very 
small quantities. It is therefore unavailable as an exclusive food. 

Oatmeal Gruel. — Oatmeal is utilized in the same manner as bar- 
ley to dilute milk. It is made up in the form of a gruel. Two or 
three teaspoonfuls of oatmeal are boiled in a pint of water for three 
hours in a double boiler and then strained. This decoction, made up 
in the same manner as the barley, is utilized to dilute milk when 
barley has a constipating tendency. 

The composition of oatmeal, according to Munk, is as follows : 



FOOD PREPARATION 8. 



115 



Water ■ 10.1 

-Proteids 14.7 

Fat 5.9 

Carbohydrates 64.7 

Kaw fibre 2.4 

Ash 2.2 

Arrowroot Gruel. — Arrowroot gruel has been used from time 
immemorial to dilute milk, especially in cases of summer diarrhoea. 
Dr. Merei is mentioned by Routh as having first suggested the use of 
this cereal for diluting milk. A teaspoonful or two of the arrowroot 
is added to a pint of water and boiled in the same manner as starch 
and oatmeal, strained, and the decoction used as a diluent with milk. 

The composition of arrowroot, according to Konig, is as follows : 

Water 16.50 

Proteids 0.88 

Fat 0.10 

Carbohydrates 81.16 

Eaw fibre 0.05 

Ash 0.19 

Beef -juice. — The principal beef -juices are Valentine's, the prep- 
aration called Puro, Bovinine, Brand's, Wyeth's, Armour's, and Bur- 
goyne's preparations of beef-juices. Beef-juices contain little protein 
and much extractive matter, so that the nutritive value is very low. 
There are some of these beef -juices, such as Bovinine, which are 
manufactured from blood rather than beef-fibre. In such a case the 



Composition of Beef-juices. 





Valen- 
tine's. 1 


Puro. 2 


Bovin- 
ine. 3 


Brand. 4 


Wyeth.5 


Armour. 6 


Bur- 
goyne. 7 


Water 

Proteids 

Extractives .... 
Mineral matter . . 


Per cent. 

51.21 

9.65 

11.16 

10.84 


Per cent. 

36.60 

30.33 

19.16 

9.79 


Per cent. 

81.09 

13.98 

3.40 

1.02 


Per cent. 

59.15 

15.45 

16.55 

8.85 


Per cent. 

44.87 

| 38.01 
17.12 


Per cent. 

74.10 

/ 8.30 

\ 9.54 

7.51 


Per cent. 

49.51 

13.00 

8.10 

14.20 



extractives are few and the proteids low; they are more in use than 
the other preparations. In order to take enough of these beef-juices 
to equal a teaspoonful of scraped meat in nutritive value, more must 
be taken than could be borne by the average stomach in illness 
(Hutchison). They are not, therefore, available as exclusive articles 
of diet for any length of time, and young children especially, whose 

1 Analysis by Dr. Candy. 

2 Fresenius (Leyden's Handbueh der Ernahrungstherapie). 

8 Food and Sanitation, Dec. 23, 1893 (Analysis by Chittenden). 

4 Analysis by Dr. Candy (unpublished). 

"The Lancet Analysis (quoted by the makers). 

6 Analysis by Dr. Attfteld (supplied by the makers). 

T Analysis by Dr. Candy. 



116 



NUTRITION AND INFANT FEEDING. 



palates are capricious, will rebel against most of these preparations, 
though they may prefer those which contain less salt than others. 
They are useful, therefore, only as articles of diet twice or three times 
in the twenty-four hours, and furnish ingredients ill the shape of 
water and salts and very little protein to the body. 

Peptone Preparations. — By peptone preparations are meant such 
preparations as Somatose, Carnrick's Peptonoids, Fairchild's Pano- 
peptone, and others. By, referring to the table the reader will see 
that there are quite a number of preparations .on the market. Of 



Showing the Composition of Peptone Preparations. 



Preparation. 


Water. 


Soluble pro- 
teids (chiefly 
albumoses). 


Extractives 
and other non- 

proteid or- 
ganic matter. 


Mineral 
matter. 




Per cent. 


Per cent. 


Per cent. 


Per cent. 


Somatose 


9.20 


80.00 




6.70 


Carnrick's peptonoids . . 


5.40 


24.00 


65.40 
(mainly sugar) 


5.20 


Koch's peptone 


40.16 


34.78 


15.93 


6.89 


Liebig's peptone 8 .... 


31.90 


33.40 


24.60 


9.90 


Brand's beef-peptone . . 


84.60 


7.00 




1.40 


Denaever's peptone . . . 


78.45 


12.15 


4.32 


2.54 


Darby's fluid meat 9 . . . 


25.71 


30.60 


30.18 


13.50 


Armour's wine of peptone 10 


83.00 


3.00 


12.90 


1.10 


Fairchild's panopeptone ll 


81.00 


6.00 


13.00 

(largely sugar) 


1.00 


Peptonized milk 12 . . . . 


87.50 


1.76 


10.04 

(= sugar, fat, 

and unaltered 

proteid) 


0.70 


Liquid peptonoids 13 










(Arlington Co.) .... 




5.25 


12.63 


0.95 



the peptonized foods in a ready form, the most concentrated by far 
is Somatose, which contains 80 per cent, of albumoses; whereas 
other preparations contain, as will be seen by reference to the table, 
very little proteid matter, and are, therefore, of very slight nutritive 
value. Somatose, however, though containing as it does the greatest 
amount of proteid matter, cannot be taken in large quantities for any 
length of time without causing diarrhoea, and in this respect it is 
unavailable as an exclusive form of food. In feeding infants and 
children I find it is of the greatest value in those cases in which it is 
necessary to give the stomach absolute rest and to feed per rectum. 
For such cases the Somatose is prepared as follows: A teaspoonful 

8 Ley den 's Handbuch der Ernahrungstherapie. 

9 Ibid. See also von Noorden, Therapeutische Monatshefte, June, 1892. 
10 Horton Smith's Journal of Physiology, vol. xii., p. 42, 1891, and Leyden's 

Handbuch. 

11 Maker 's analysis. 

ia Horton Smith (loc. cit.). 

33 Maker 's analysis also contains 14.94 per cent, of alcohol by weight. 



FOOD PREPARATIONS. 1 1 7 

of Somatose is dissolved in eight ounces of cold water. Two ounces 
of this solution is given carefully per rectum, care being observed 
to pass the catheter above the second sphincter, in order that the food 
may not be rejected. This may be repeated every few hours. Thus 
given, a rectal enema is absorbed for the most part, and in some cases 
it may be mingled with milk part for part, the nutritive properties 
being thus increased. 

Butter Milk. — Butter milk was first proposed as an infant food 
by Ballot in 1865 and recently revived and perfected as a substitute 
for the breast milk by Teixeira de Mattos. According to the latter 
it is prepared as follows: A litre of butter milk (commercial) is 
mixed with a level tablespoonful of rice, wheat or any cereal flour 
and stirred constantly over a low flame for 25 minutes. During this 
time it is brought to a boil three times after having added two to 
three tablespoonfuls of cane or beet sugar. The advantages of such 
a mixture for sick infants is that it has a very low fat and a very 
high proteid content. Inasmuch as the mixture has been boiled and 
some advise that bicarbonate of soda be added to a point of alkalinity, 
the acidity of the butter milk and its supposed bacterial nature have 
nothing to do with its favorable effects. It is an uncertain food to 
use, as some butter milks are distinctly dangerous and their prepa- 
ration has not yet been so perfected that we can avoid this danger. 

Kumyss. — Kumyss has the following composition (Konig) : 

Water 90.44 

Alcohol 1.91 

Lactic acid 0.91 

Milk sugar 1.77 

Proteid 2.44 

Fat 1.46 

Ash 0.42 

Originally kumyss was made from mares' or camels' milk by the 
addition of a ferment indigenous to Tartary, called kefir. To-day 
kumyss is manufactured from cows' milk by the addition of ordinary 
yeast-fungus, and contains, as will be seen by reference to the table, 
a certain amount of alcohol and lactic acid. I have never succeeded, 
even for a short period of time, in feeding infants on kumyss with 
any amount of satisfaction. It is only available in illness of older 
children with capricious palates. Its use, therefore, is exceedingly 
limited. The same may be said of Matzoon. 

Beef-extracts. — Beef-extracts are open to the same objections as 
beef-juices, in that they contain for the most part extractives and 
are not intended for prolonged periods of use. There are prepara- 
tions, such as Bovril's, which contain meat-fibre, but which musl be 
given in such concentrated form to obtain the necessary nutriment 



11 



NUTRITION AND INFANT FEEDING. 



as to cause diarrhoea. Beef-extracts, on account of the warmth and 
contained salts, are supposed, when administered, to- stimulate the 
appetite. A teaspoonful of Bovril's is equal to 8 grammes of lean 
meat, and therefore must be given in very large quantities, as stated 
above, in order to obtain any amount of nutrition. 

Beef-broth. — Beef-broth has a composition of proteids 0.4, fat 
0.6, salts 1.2, and extractives 1.2. With the extractives beef -broth 
contains creatin, xanthin, and hypoxanthin. 

One pound of meat is cut up, placed in one pint of water, and 
allowed to stand for four or five hours. It is then cooked over a slow 
fire for one hour. After cooling, the fat is skimmed off. This makes 
a very agreeable beef-broth. 






Table 


Showing 


the Composition 


of Beef-extracts. 1 






Liebig's 
extract. 2 


Bovril. 3 


Bovril for 
invalids. 4 


Armour's 
extract. 5 


Brand's 
essence. 6 


Vejos. 7 


Water 

Proteids .... 

Gelatin 

Extractives . . . 
Mineral matter 
Ether extract, etc. 


Per cent. 
18.3 

},4{ 

30.0 
23.6 
18.6 


Per cent. 
44.40 
16.94 

20.32 
18.32 


Per cent. 

21.82 
21.42 

39.60 
17.16 


Per cent. 

15.55 

8.73 

2.16 

43.23 

25.91 

4.12 


Per cent. 
87.17 
5.40 
5.03 
1.01 
1.39 


Per cent. 
25.02 
19.35 

21.02 
14.07 
17.09 

(Carbo- 
hydrate). 



In addition to the above, beef-broth contains phosphate of cal- 
cium, earthy phosphates, sodium chloride, oxide of iron ; the nutrition 
obtained from it depends mostly on the salts, especially of calcium 
combined with those of the phosphorus. 

Acorn Cocoa. — Acorn cocoa is a preparation made in Germany, 
and may be obtained on sale in the shops. The author has found 
it of especial use in cases of diarrhoea and intestinal disease in which 
it is advisable to suspend the use of milk. It may be given for some 
days. Children, however, object to its taste, and for this reason it 
is not applicable in every case. It contains fat, nitrogenous matter, 
and tannic acid. A teaspoonful of the cocoa is dissolved in eight 
ounces of water, and the preparation is given warm in much the same 
manner as milk. 

1 Hutchison, The Lancet, 1902. 

2 Analysis by Tankard. 

3 Analysis by Stiitzer (quoted by Voit, Munchener medicinische Wochenschrif t, 
No. 9, 1897). 

* Analysis supplied by the company. 
6 Food and Sanitation, Dec. 16, 1893. 

6 Analysis by Dr. Candy (unpublished). 

7 The Lancet, April 16, 1898, p. 1060. 

N. B. — " Vejos " is a purely vegetable product, but is included in this table 
for convenience. 



ARTIFICIAL INFANT FOODS. 119 

Stohlwerck's acorn cocoa has the following composition: 

Water (Presenilis, Konig) 5.28 

Proteids 14.06 

Fat 14.42 

Sugar 25.15 

Tannates 1.96 

Extractives 23.39 

ARTIFICIAL INFANT FOODS. 

Infant foods have been the subject of much investigation on the 
part of the profession. Scientifically the physician is correct when 
he maintains that children cannot be brought up, as a rule, on the 
exclusive use of any infant food. 

The infant foods present to the practitioner either dried milk, a 
cereal in combination with it or alone, with or without the addition 
of a malt preparation of some kind. It is quite evident, therefore, 
that there are several serious objections to them as exclusive articles 
of diet for a great length of time. The principal objection is that 
they are dried or heated food substances. In a majority of cases 
this is a dangerous article to use for a prolonged period in infancy 
and childhood without combining it with some fresh article of diet, 
such as cows' milk. 

Again, many of the infant foods contain nothing but a dry, care- 
fully prepared cereal. It is evident that this alone cannot be given 
as an exclusive article of diet to an infant. It may be administered 
for a short time, as will be pointed out in the article on Infant- 
feeding; but it cannot be given for any prolonged period without 
giving rise to those very symptoms which we all fear referable to the 
bones and the circulatory system; evidence of disturbed nutrition, 
such as rachitis and scurvy. 

We may divide infant foods roughly into three groups : The 
first group, such as Allenbury's, Horlick's, Carnrick's, and Nestle's 
Food, contain cows' milk desiccated, combined with some cereal and 
sugar. These foods are intended as an exclusive diet for infants, 
and against these the scientist objects principally. They are foods 
which cannot be applied as an exclusive food, and which if given over 
a prolonged period are open to the objections stated above. 

The second group of infant foods are possibly the most useful, 
and are those which contain some form of malted carbohydrate. The 
carbohydrates are in soluble form and the food may be regarded as 
a desiccated malt extract. Some of these preparations also contain 
diastase, and by combining the food with cows' milk or by the addi- 
tion of some carbohydrate to the milk we can obtain a combination 
which is not only digestible for the infant, but may be of great 



120 



NUT BIT I OX AND INFANT FEEDING. 



nutritive value for a short period of time. In this group belong 
Mellin's Food, Loenund's Malt Soup, the latter being nothing more 
nor less than the Liebig Malt Extract combined with potassium 
carbonate. 

The third group of infant foods are those which are constructed 
of a pure cereal, and in this group are Ridge's Food, Imperial 
Granum, Robinson's Patent Barley, and others. This last group 
may simply be considered as very carefully prepared cereals. They 
apply in those cases of intestinal disorder in which it is desirable for 
a short period of time to exclude milk completely. 

These foods, including condensed milk previously mentioned, 





Composition 


of Infant Foods. 1 


Food. 




"3 

c 


+3 


6 

. "§ 
c H 




General description and remarks. 




£ 


Si 






§ 






Per 


Per Per Per 


Per 






cent. 


cent. cent. cent. 


cent. 




Dried human milk . . 




12.20 26.40 52.40 


2.10 


The standard of composition to which 
artificial substances should con- 


Geoup I. 








form. 


Allenbury No. 1 . . . 


5.70 


9.70 14.00 66.85 


3.75 


Desiccated cows' milk from which 


(For children before 








the excess of casein has been re- 


the age of three 








moved, and a certain proportion of 


months.) 








soluble vegetable albumin, milk, 
sugar and cream added. No starch 








present. 


Allenbury No. 2 . . . 


3.90 1 9.20 12.30 i 72.10 


3.50 


Kesembles the above, but contains 


(For children from 












some malted flour in addition. No 


the age of three to 












starch present. 


six months.) 














Horlick's malted milk 


3.70 


13.80 


3.00 


76.80 


2.70 


A mixture of desiccated milk (50 per 
cent.i, wheat flour (26 l 4 per cent.!, 
barley malt (23 per cent.), and bi- 
carbonate of soda (% per cent. i. 
Contains no unaltered starch when 
mixed. 


Carnrick's soluble food 


5.50 


13.60 


2.50 


76.20 


2.20 


A mixture of desiccated milk (37V2 
per cent.), malted wheat flour (37 1 ; 
per cent, i, and milk-sugar (25 per 
cent.). When prepared according 
to directions the casein is partially 
digested, but a considerable amount 
of unchanged starch is left. 


Nestles milk food . . 


5.50 


11.00 


4.80 


77.40 


1.30 


A mixture of desiccated Swiss milk, 
baked wheat flour, and cane-sugar 
(30 per cent ). More than a third 
of the total amount of carbohy- 
drate is in the form of starch. 


Manhu infant food . . 


8.86 


8.70 


5.60 ; 75.90 


1.00 


A mixture of desiccated milk and 
malted cereals. When prepared 
according to directions contains a 


Group II.— Class A. 






good deal of unaltered starch. 


Mellin's food 


6.30 7.90 trace 82.00 


3.80 


A completely malted food. All the 
carbohydrates in a soluble form. 












May be" regarded as a desiccated 
malt extract. 


Class B. 










Savory & Moore's food 


4.50 10.30 1.40 


83.20 


0.60 


Composed of wheat flour with the 
addition of malt. 


Benger's food 


8.30 10.20 1.20 


79.50 


0.80 


A mixture of wheat flour and pan- 
creatic extract. 


Allenbury malted food 


6.50 9.20 1.00 


82.80 


0.50 


A mixture of wheat flour and malt. 
When prepared according to direc- 
tions it still contains some unal- 














tered starch. 



1 Eobert Hutchinson, Lancet, 1902. (Abbreviated by the author). 



ARTIFICIAL INFANT FOODS. 



121 



Composition of Infant 


Foods ( Continued). 


Food. 




•6 




■*-■ 

O JH 

fit 


1| 
g3 


General description and remarks. 




ts 


o 
u 


H 




•hS 






^ 


Pw 


fc 


0~ 


« 




Group II.— Class B 


Per 


Per 


Per 


Per 


Per 




{Continued). 


cent. 


cent, 


cent. 


cent. 


cent. 




Diastased farina . . . 


8.30 


7.60 


1.30 


81.70 


1.10 


A malted farinaceous food. When 
prepared according to the direc- 
tions, practically all the starch is 
converted into soluble forms. 


Coomb's malted food 


7.90 


12.10 


2.80 


76.80 


0.40 


A malted farinaceous food. 


Nutroa food 


6.80 


15.90 


10.30 


66.00 


1.00 


A mixture of cereals with the addi- 
tion of a certain proportion of pea- 
nut flour, from which the some- 
what bitter taste of the food and its 


Group III. 












high proportion of fat are derived. 


Ridge's food 


7.90 


9.20 


1.00 


81.20 


0.70 


A baked flour, containing only 3 per 
cent, of soluble carbohydrates, the 
„ remainder being starch. 


Neave's food 


6.50 


10.50 


1.00 


80.40 


1.60 


Resembles the above. 


Frame food diet . . . 


5.00 


13.40 


1.20 


79.40 


1.00 


A thoroughly baked flour to which 
have been added cane-sugar and 
some extract of bran. 


Opmus food 


10.90 


9.10 


1.00 


78.60 


0.40 


A granulated wheat food. 


"Falona" 


7.00 


8.40 


3.50 


79.90 


1.20 


A mixture of cereals (oats, barley, 
and wheat), with a ground fat- 
containing bean. 


Robinson's groats . . 


10.40 


11.30 


1.60 


75.00 


1.70 


Ground oats from which the husk 
has been removed. 


Robinson's pat. barley 


10.10 


5.10 


0.90 


82.00 


1.90 


Ground pearl barley, poor in every 
element except starch and mineral 


























matter. 


Chapman's whole flour 


8.40 


9.40 


2.00 


79.30 


0.90 


A finely ground whole-wheat flour. 


Scott's oat flour . . . 


5.80 


9.77 


5.00 


78.20 


1.30 


A fine oat flour. 


Addenda. 














Imperial granum . . 


9.23 


14.00 


1.04 


75.34 


0.39 


(Classified under Group III.) 


Eskay's food 


8.58 


5.82 


1.16 


89.02 


J. 30 


(Classified under Group I.) 



show a deficiency of fat and an excess of carbohydrates. On this 
ground alone their prolonged use is objectionable. The proteids 
present are either in the form of dried, heated proteids of cows' milk, 
one of the most indigestible forms of proteid substances that can be 
given to the infant, or in the nature of vegetable substances which 
are foreign to the infant dietary. Condensed milk also contains such 
an excess of sugar as to cause acid dyspepsia ; although preparations of 
condensed milk are made up, as has been stated, without sugar. ' In 
the treatment of enteritis, both of the acute and subacute type, it is 
essential in very young infants to give temporarily some form of 
food which does not contain milk in any form. Although an ordi- 
nary cereal may be used in these cases, a more agreeable form is one 
of the infant foods, and especially Imperial Granum. This, made 
up to the consistence of ordinary barley-water, may be administered 
in cases of ileocolitis for quite a length of time, and will nor be 
rejected by the infant or young child. 

At the period of weaning — the ninth month- cereals may be 
added to the milk, in the form of an infant food, such as Ridge's 
Food, Imperial Granum, or barley. In such cases the barlej 



or 



122 NUTRITION AND INFANT FEEDING. 

infant food is well borne. It must not be forgotten also that in the 
malted foods, when added to the milk, we are giving a form of sugar, 
malt-sugar, one of the most digestible carbohydrates. 

The objection raised to the combination of malted foods, starchy 
cereals, and milk, that the infant is not capable of digesting starch, 
does not obtain fully in practice. We find, as will be shown in case 
of the dextrinized gruels, that large quantities of carbohydrate and 
flour may be given to infants, and their digestion will not only be 
normal, but they will thrive and increase in weight very rapidly; 
whereas, under an ordinary milk diet they have remained atrophic. 

MATERNAL NURSING. 

The ideal food for the infant is the milk of the mother s breast. 
Under our social conditions, the mother who can nurse her child 
from birth to the period of weaning is an exception to the rule, not 
because most mothers do not wish to nurse their infants. On the 
contrary, the author has found them very anxious to perform this 
function, but the average mother to-day has not the physical develop- 
ment that fits her to nurse the child. The result is that she cannot 
furnish sufficient milk, or that the milk is not of the quality requisite 
for successful nursing. Some mothers will have a sufficiency of 
so-called milk. The infants, however, do not gain in weight, are 
puny, have attacks of colic, and the symptoms indicate that the food 
is at fault. Examination shows that in such women true milk secre- 
tion is rarely established; the milk remains in the colostrum stage. 

Some physicians think that if the infant cannot have the benefit 
of the maternal breast a wet-nurse is the alternative. If with the 
wet-nurse we had simply to consider the fitness of the food, this would 
be true. If the maternal breast is not at our disposal, the next best 
and the safest thing for the race is a substitute for the breast, for 
many reasons, some of which we will try briefly to indicate. 

In the first place, it is not moral nor conducive to the future 
good of the race to ask a mother (the wet-nurse) to put aside her 
own child and to deprive it of the breast for the sake of a strange 
child. 

Second. No matter how healthy a wet-nurse may be at the time 
of examination, we have no assurance that such a wet-nurse will 
remain healthy, or that some diathesis not apparent at the time of 
examination may not be transmitted to the infant (Czerny). We 
thus take a healthy infant, place it at a breast, and feed it with milk 
concerning the ultimate influence of which we are utterly in the dark. 
The author is inclined to believe that so far as human milk is con- 
cerned, certain tendencies may be conveyed from the nurse to the 



MATERNAL NURSING. 1 23 

infant which will crop out later in life. By this he refers rather to 
scrofulous tendencies, lymphatic tendencies, tendencies connected 
with diseases of the blood-forming organs. 

Third. The introduction of a stranger into the household is a 
cause of great disturbance to that household, and also one of concern 
to the physician. The idea that a child brought up at the breast is 
better fitted for the struggle for existence may be true ; on the other 
hand, the difficulties, at least in this country, of obtaining fit wet- 
nurses for children are so great that it would be well, if the mother 
cannot nurse the infant, to place it on a substitute in the form of 
bottle-feeding, unless this is not feasible. 

Of course, in all this we do not include those exceptional infants 
which cannot be fed artificially. Such cases occur, and must be 
placed upon the breast. 

Finally, if the mother can furnish two or three nursings daily, it 
is well not to take the child off the breast entirely, but to institute 
what is known as mixed feeding. In some cases this is a very satis- 
factory method of feeding the infant. 

Contraindications to Maternal Nursing. — A mother may suffer 
from syphilis or skin eruptions or may have a deficiency of milk and 
under certain conditions may still be allowed to nurse her infant. A 
wet-nurse should be free from all constitutional and psychical taint 
to nurse an infant. 

Syphilis can be communicated to the wet-nurse by the infant, or 
to the infant by the wet-nurse through luetic lesions of the nipple. 
A syphilitic infant, therefore, must not be allowed to nurse the breast 
of a woman who is free from syphilis ; and we should be very careful 
not to place a child free from syphilis on the breast of a wet-nurse 
without previous careful examination as to the presence of syphilis 
in the nurse. A mother, on the other hand, who has syphilis can 
nurse her infant without danger of communicating syphilis to the 
infant if the mother has been exposed to and contracted the disease 
up to a period of two months before the delivery of the child. An 
infant congenitally syphilitic may nurse its mother without commu- 
nicating the disease to the mother. These facts have been well estab- 
lished, and have been commented on in the chapter on Syphilis. 
Should the mother have contracted syphilis subsequent to the birth 
of her infant, and should she have been nursing the infant, it would 
be wise to take the infant away from the breast, for such a mother 
may communicate the syphilis to the infant in the same manner as a 
syphilitic wet-nurse. 

Tuberculosis in the mother, even in its milder manifestations, is 
a contraindication to her nursing her infant. Though the manner 
in which the toxins of the tubercle bacillus or the bacillus itself pass 



124 NUTRITION AND INFANT FEEDING. 

into the breast milk, if such be the case at all, is still a matter of 
study, we can well understand how the mother, weakened by the 
inroads of such a disease as tuberculosis, would be further seriously 
injured and weakened by nursing her child. The close contact of 
mother and nursling, furthermore, might favor the infection of the 
infant in other ways than by the milk alone. On the other hand, an 
old focus of tuberculosis, such as a healed pleurisy or coxitis long 
healed, in a vigorous mother would not contraindicate nursing should 
the secretion of milk be abundant and should the function not make 
inroads upon her health. 

Active symptoms of Bright's disease, such as general anasarca 
and other signs of serious involvement of the kidney, would preclude 
a mother's nursing her infant, not only because such a function would 
weaken her, but because, metabolism being profoundly disturbed, the 
breast milk would be unfit for the maintenance of the nutrition of 
the infant. 

Advanced disease of the heart would also unfit a woman for 
nursing her infant. On the other hand, a slight albuminuria not 
giving any objective or subjective symptoms should not interfere 
with the desire of the mother to nurse her offspring. Advanced 
and active disease of the liver would in the same manner as the above 
diseases contraindicate nursing. 

Organic nervous disease with paralysis, severe neuroses, insanity, 
hysteria, epilepsy, neurasthenia of a marked type, when present in 
the mother, contraindicate the nursing of the infant. Aside from 
the disturbances said to be caused in the infant nursing the breast of 
a person the subject of hysterical or epileptic attacks, we would 
scarcely care to trust such a sufferer with the care of an infant. On 
the other hand, slight nervous tendencies in the mother should not 
contraindicate the nursing of the infant, for in such a case we would 
open the way for the deprivation of the breast to a large number of 
infants, and give an easy avenue of escape to some from the responsi- 
bilities of maternity. The severe forms of anaemia, leukaemia, ma- 
lignant disease, such as carcinoma and sarcoma, the presence of a 
very marked goitre with active symptoms, may be mentioned as con- 
traindications to the nursing of an infant. 

The acute contagious diseases, the exanthemata, erysipelas, pneu- 
monia, bronchopneumonia, pleurisy, acute rheumatism, typhus and 
typhoid fever, diphtheria, are all contraindications to nursing the 
infant. I have seen mothers suffering from erysipelas nurse their 
infants without infecting them. This should not be the rule, how- 
ever. In a case of diphtheria the danger to the infant of infection 
is much greater than would be counterbalanced by the benefits to be 
attained from continuance at the breast. The milk of a woman suf- 



PLATE VI 



FIG. 1 




Form of the Breasts of a Wet-nurse with Abundant 

Milk Of Good Quality. (After Schliehter ) 



FTG. 2 




Form of the Breasts of a Wet-nurse whose Milk is 
Deficient in Quantity and Quality. (After SchliohterO 



MATERNAL NURSING. 1 25 

fering from a severe pneumonia with a high febrile curve cannot be 
all that is desired for the infant, and the process of nursing with the 
accompanying physical and mental disturbance might react against 
the mother. 

Selection of a Wet-nurse. — It is not necessary that the wet- 
nurse should have been recently delivered. A newborn baby may be 
given the breast of a nurse whose baby is from one to two months of 
age. In fact, her milk is preferable to that of a nurse who has just 
been confined. For, apart from the uncertainty as to whether the 
milk will agree with the baby, the milk after a few weeks attains a 
uniform composition, and is more likely to agree with the baby than 
milk from the breast of a woman recently confined. I prefer to place 
the newborn infant on a breast at least three weeks old. 

The method of examining a wet-nurse as to her fitness begins 
with ascertaining the history of her own baby. It should sleep well 
in the intervals of nursing, be free from colic, and have normal move- 
ments. The baby should be completely undressed for examination. 
It should be at least tolerably well nourished. There should be no 
eruption on the skin, no copper-colored intertrigo, no snuffles, no pig- 
mented spots, and no rhagacles around the mouth or anus. The skin 
of the palms of the hands or the soles of the feet should not be fissured 
or hard or present suspicious pigmentation. The head should not 
have an idiotic, microcephalic conformity. The wet-nurse should be 
below the age of thirty. Old multiparas do not, as a rule, furnish 
good milk. The shape of the breast is important. The pear-shaped, 
elongated, hanging breast furnishes more milk than the firm, round 
breast of virgin shape (Plate VI.). The nipple should be about one 
centimetre long and three-fourths of a centimetre in diameter. The 
baby can easily grasp such a nipple and draw it into the mouth. A 
flat nipple, or a nipple with fissures, or a nipple surrounded by eczema 
is not desirable in a nurse, and may even be dangerous to an infant. 
The nurse is next directed to undress, and her body is examined for 
traces of any eruption which may be specific. Pigmented macules 
should arouse suspicion, as also enlarged cervical or epitrochlear 
lymph-nodes. The lungs, especially the apices, are examined for 
bronchitis or tuberculosis. The nurse is rejected if there be the 
slightest evidence of apical involvement. The teeth should not be 
carious to such an extent as to preclude the possibility of their being 
kept clean. The presence of a foetid ozsena is highly objectionable, 
apart from the offensive odor. Such cases may be latently tuber- 
culous. The woman should be mentally sound. The wet-nurse is 
then examined as to the presence of venereal disease by inspection 
of the introitus vaginae and (lie anus. The mucous membrane of 
the mouth should be examined for evidences o( syphilis. Search is 



126 NUTRITION AND INFANT FEEDING. 

made for mucous patches and suspicious cicatrices. After having 
examined both child and mother in the manner detailed, we are in a 
position to recommend the nurse if the milk is satisfactory. 

The physician should have at hand in his office means by which 
he can at once decide upon the desirability of a wet-nurse. He must 
not at the beginning be driven to the necessity of a milk analysis. 
He decides first as to the quantity and then as to the quality of the 
milk. As a rule, a wet-nurse comes to the physician insufficiently 
fed and in a frame of mind far from tranquil. If despite these con- 
ditions the milk possess the qualities desired, he may at once venture 
to place the baby at her breast. If the milk does not agree with the 
baby after a fair trial, future conduct will be guided by certain 
developments, both in the quantity and quality of the milk and the 
condition of the infant. 

Quantity of the Milk.— The physician grasps the breast in the 
palm of his right hand and gently but firmly attempts to express 
the milk. The milk should with gentle pressure flow freely from 
the ducts. A drop is caught on the nail of the thumb. This time- 
honored nail-test is not to be despised. A drop of good milk will 
retain its bluish-white tint. This test will bring out the color of 
the milk, whether too watery, yellow, or white, to the experienced 
eye. The nurse is then directed to pump by gentle pressure a quan- 
tity of milk into a long, narrow beaker glass. If the breast has not 
been nursed within an hour, there should be no difficulty in obtaining 
at least an ounce of milk in this way. With this quantity we can 
at once decide on the efficiency of a nurse. The milk should have a 
bluish-white tinge. Any trace of yellow or green when a test-tube 
of the milk is held in the light, is abnormal. Milk may be very 
abundant but of a dirty white tinge; some specimens separate almost 
instantly upon withdrawal into a yellowish oily layer on top and a 
serous liquid below. Any such abnormalities in the milk should 
cause the rejection of an applicant. If the breasts, history, and 
physical examination are satisfactory, and the quantity and physical 
characteristics of a nurse's milk are good, we may recommend her 
without making a chemical examination of the milk. Such an 
examination is impracticable for the practitioner with the means at 
his disposal. Even if carried out, it may be unfair to the nurse. 
At the examining visit the proportion of proteids and fats may be 
below what it will adjust itself to in a day or two when the wet-nurse 
is rested and housed in her new home. More nutritious diet will 
greatly change the composition of the milk. There are, however, 
conditions which may require an examination of the milk at a sub- 
sequent period. In such a case the methods detailed elsewhere may 
be resorted to. 



MATERNAL NURSING. 127 

The Beginning of Nursing. — Once having determined to place 
the infant at the breast, the question arises, When should this func- 
tion be begun ? Immediately after birth the mother is tired and so 
is the infant. They have both gone thought a critical period. It is 
well to let them rest for some hours. If the infant sleeps, and 
awakens only to be changed as to its diaper, we should not hasten 
to feed it. The author follows the rule that the infant be given a 
little water at intervals from the first six hours until the beginning 
of the next day after birth, and then the mother, having been thor- 
oughly rested, the child is put at the breast, even though there are 
but a few drops of colostrum in the breast. 

The first day after birth the infant should be fed at intervals 
of three hours. At this time there will be very little in the breast, 
but the stimulation of the breast by nursing will cause an increased 
secretion of milk, so that by the second day nursing may be inaugu- 
rated at regular intervals of two hours. After this the intervals of 
nursing are so apportioned that the newborn infant during the first 
week will obtain the breast from nine to ten times in the twenty-four 
hours ; the second week, eight or nine times in the twenty-four hours ; 
and in the fourth week, eight times in the twenty-four hours. After 
this the intervals of nursing will be much the same as they are in 
artificial feeding. We give the breast at intervals, generally of two 
and a half hours, so that the last nursing is at 11 p. m. After the 
first month the infant should sleep until ^vq or six o'clock in the 
morning, when it obtains the first nursing. Then from the second 
to the sixth month seven nursings in the twenty-four hours are suffi- 
cient. The nursing should be so arranged that the mother and child 
may have complete rest of five hours between 12 p. m. and 5 a. m. 

The number of times an infant should nurse at the breast is in 
the large majority of cases a matter of training and habit, especially 
with the breast-fed infant. Czerny, following, Ahlf eld advises placing 
the baby at the breast on the average of five times in the twenty-four 
hours. With care and patience this can be done. The practitioner, 
however, will meet a number of mothers who will nurse their offspring 
more frequently, and the above gives the limit of such nursings. In 
frequent nursing the infant receives less at each feeding than in the 
nursings at longer intervals. 

Care of the Breast. — The care of the breast really begins before 
the birth of the infant. About the seventh month of pregnancy colos- 
trum appears in the breast. At this time it can be seen in some cases 
to exude from the nipple. Unless care is taken at this time we will 
have a fissuration of the breast nipple, due to the action on the epi- 
thelium of the skin of the drops of colostrum which are allowed to 
collect and decompose on the nipple. The result is that ar birth 



128 NUTRITION AND INFANT FEEDING. 

the mother may have sufficient milk in the breast, but be unable 
to nurse the child on account of the presence of these fissures. I 
advise, therefore, that at this time of pregnancy the nipples be kept 
scrupulously clean and washed twice a day with a dilute solution of 
alum water or some antiseptic wash. In this way the decomposition 
of colostrum on the nipple is avoided, and the nipple is strengthened 
by the slight massage of washing. If the nipple is not well devel- 
oped, this is the time also to attempt its development. This is done 
by drawing out the nipple twice a day, either with the clean fingers 
or by means of suction. A small clay pipe may be used for this pur- 
pose, and the future mother may draw out the nipple by means of 
suction with this simple instrument. I am certain if this hygiene of 
the nipple is pursued that fissures of the nipple will be less frequent. 

Fissured Nipples. — Ordinarily, if the nipple of the breast is kept 
dry and clean, it will not fissure and eczema will not occur. Fissures, 
however, sometimes occur even when great care has been taken to 
prevent them. Fissures or rhagades appear in about one-half of the 
nursing women. They are present either on the summit of the 
nipple or at its base. In the latter situation they are in the form of 
linear or circular ulcers. If fissures of the nipple are painful, the 
infant should not nurse the breast directly, but through a shield 
which protects the nipple, the best form being the Davidson shield. 
The fissure is painted once daily with a 10 per cent, solution of 
nitrate of silver. If there is a discharge of visible pus from the 
fissure, or if the breast nipple has a point of suppuration ever so 
small, the breast should not be nursed, for by so doing the mother 
may develop abscess of the breast or the infant may contract an 
infectious diarrhoea. 

Physicians insist on placing infants at the breast immediately 
after delivery, for two reasons: first, because it is said that suction 
at the breast favors contraction of the uterus. Whether with this 
function there is contraction of the uterus has not been proved. 
Again, it is said that at this time suction will favor the flow of milk. 
Milk with colostrum does not appear to an appreciable amount in 
the breast, if not previously present, before twenty-four to seventy- 
two hours or even eight days after delivery. If, as has been pointed 
out, the breast is nursed too frequently, the traumatism caused by a 
vigorous infant will give rise to erosions of the nipple, and thus 
fissures. An excellent nursing breast may be ruined by over-zealous 
efforts on the part of the physician. Fissures once present, if 
unyielding to the methods detailed above, must be allowed to heal by 
giving the breast perfect rest. Some women will nurse an infant at 
the breast, the nipples of which are the seat of fissuration, without 
pain, caking, or inconvenience. In other women caking will take 



MATERNAL NURSING. 129 

place, with intense pain on nursing, and lymphangitis and abscess 
result. In all such cases of pain, lymphangitis, and caking nursing 
is best suspended, the infant being placed temporarily on the bottle. 
The breasts are supported, the fissures painted daily with silver, and 
if caking is present the breasts are emptied carefully with the pump 
and massage of the breasts performed. If after the breasts become 
soft and the fissures are entirely healed there is still a little milk in 
the breast, the infant may be put again at such a breast, and if the 
organ is in a normal state the stimulation of suction will start a 
proper milk secretion. I have done this in a case in which the 
breasts had been at rest for three weeks after delivery, with excellent 
results. The milk returned in abundance, without unnecessary trau- 
matism to the breast, the infant nursing only three times daily at 
first. We should never expose a mother to the danger of abscess of 
the breast by persistent attempts at nursing fissured nipples. 

Caking of the Breast. — After the birth of the infant, the breast 
should be closely watched to prevent the so-called caking of the milk. 
If the infant is not strong and does not nurse well, there will be a 
residual amount of milk in the breast. After nursing, this milk 
should be pumped off with a breast-pump. The most satisfactory 
breast-pump is one with a glass bell and a rubber bulb. Pumping 
the breast at first, when the milk is forming, will prevent caking and 
rapidly regulate the secretion to the normal amount. On the other 
hand, if a fissure of the nipple is present, caking is more apt to 
occur, on account of the pain attendant on emptying the breast, either 
by nursing or by means of the breast-pump. We should be exceed- 
ingly cautious in these cases to examine the breast repeatedly in order 
that areas of caking may not escape us. 

If caking occurs, the breast should be rubbed or massage per- 
formed three times daily. The hands of the nurse are carefully 
washed and anointed with some sterilized oil. The breast is grasped 
in the palms of both hands, one above and the other beneath. The 
breast is then gently subjected to firm pressure with a vermicular 
motion. This massage is kept up for five or ten minutes. 

Nursing the Infant. — The infant should nurse about twenty 
minutes and then fall asleep at the breast. The nipple is washed 
with a solution of boric acid before and after each nursing, and is 
covered in the intervals of nursing with a small piece of absorbent 
gauze folded several times. In this way the nipple does not come 
in contact with the clothing, and any exuding milk is caught on the 
gauze, which is replaced by a clean piece whenever necessary. The 
infant while nursing should lie in the arms of the mother or the 
nurse. The nurse grasps her breast just behind I ho base of the 
nipple with the index and ring fingers; (ho thumb should bo used 

9 



1 30 NUTRITION AND INFANT FEEDING. 

to exert pressure on the breast and thus regulate the flow of milk. 
In this way the infant is prevented from drawing the nipple too far 
into the mouth. The habit of moistening the breast with saliva or 
a few drops of milk is reprehensible. The infant's mouth will fur- 
nish all the moisture needed. 

Signs of Efficient Breast-feeding. — An infant nursed at the 
breast is thriving if it has a good color, if its weight increases in 
regular ratio, if it sleeps between the ' nursings, and the stools are 
normal in color. It may be said in this place that, as to the stools, 
they will vary even in the most thriving infant, both in color and 
consistence, from time to time. An infant who is otherwise in good 
health and is not suffering from any disturbance of the gut will have 
from time to time slightly fluid, yellow movements; at other times 
the movements may contain a few whitish curds ; and at other periods, 
even the most thriving breast-fed infants may show in the stools 
greenish discolored particles. If the infant shows no other signs of 
disturbance and is in good spirits, these changes in the color and 
consistence of the movements should not give us concern; they are 
dependent on the varying composition of the breast-milk. If the 
milk contains on certain days more fat than usual, the movements 
may be softer and more frequent than customary. If the proteids 
are increased in quantity they may even show a greenish tinge. 
These conditions, however, must be infrequent and should not carry 
with them disturbances, such as colic, restlessness, or stationary 
weight. 

I have seen infants who were thriving, in that they had a very 
good color and their weight increased, but they suffered from inordi- 
nate colic, and examination of the breast milk showed, even at the 
second month of infancy, quite a number of colostrum corpuscles. 
After certain hygienic hints were carried out by the mother, these 
colostrum corpuscles disappeared from the milk, the colic abated, 
and the infant returned to a normal condition. Disturbances, there- 
fore, of the gut are not always an indication for the cessation of 
maternal breast-nursing. 

Signs of Inefficient Breast-feeding. — An infant is not thriving 
on the breast milk if its weight remains stationary for any length 
of time. For this reason infants should be weighed once a week at 
first, and after the second month at least twice a month. At the 
first indication of stationary weight an infant should be weighed 
every three days, in order to see whether there is any increase under 
new conditions. If the weight continues stationary the milk should 
be examined. It may be deficient in quantity to such an extent as 
to no longer satisfy the child. In that case the infant will be ob- 
served to nurse the breast for a long time, or it may nurse the breast 



MATERNAL NURSING. 



131 



a short time and then relinquish the nipple and cry ; or it may cry 
in the intervals of nursing. All these are signs of inefficient feed- 
ing. In such cases the breast should be examined just before a 
regular nursing, in order to estimate the quantity of milk in the 
breast. The infant should be weighed, then given the breast, and 
weighed after nursing is completed. The breast is also examined 
after nursing. In this systematic way we can estimate the amount 
of milk taken by the infant at that particular nursing. 

The movements of infants fed on an inefficient breast as to the 
quantity of milk are dry, constipated, and small. The author has 
seen the character of the stools improve upon increasing the quantity 
of food, either from the breast or by supplementing the breast with 
the bottle. In some cases the infant cries and has colic, the move- 
ments are passed with much flatus, and are uneven in consistence, 
lumpy here and there, with green discoloration. In such a case the 
quantity of the milk may be sufficient, but its quality is not up to 
the requisite standard. The nurse's milk should be examined not 
only chemically, but microscopically. A single chemical examina- 
tion of the milk, as has been stated, gives no definite information. 
The milk, therefore, of the morning and evening nursings should be 
examined. 

It may again be emphasized that colic alone or combined with 
slight variations in color and consistence of the infant's stools is not 
a justification for the suspension of nursing. An infant may gain in 
weight, have good color, and still have inordinate colic. With 
patience and hygienic exercise on the part of the nurse colicky 
attacks will ultimately grow less frequent, and many infants who 
suffered colic at first will, as the second month approaches, cease 
to have colic as soon as the milk has definitely assumed a uniformly 
normal composition. Infants who thus have suffered colic at the 
second or third month after birth will cease to be inconvenienced 
and will thrive from this time forward. 

If an infant at the breast fails to increase in weight, and at the 
same time suffers from inordinate colic, has green, curdy movements 
or a slight tendency to diarrhoea, it becomes a very important ques- 
tion as to whether it is not better to take such a child from the 
breast entirely, and to place it either on another breast or a substi- 
tute for the breast. An examination of the breast milk will aid us, 
as has been intimated elsewhere. If this breast milk reveals to any 
marked degree elements such as colostrum corpuscles and fails to 
show the characteristics of normal breast milk, we will still be more 
anxious to take such an infant from the breast. In fact, a con- 
tinuation of an infant at such a breast is sometimes not devoid of 
danger. In one case the continued attacks o( colic, accompanied by 



132 NUTRITION AND INFANT FEEDING. 

fluid movements, with green curds from birth, resulted ultimately in 
an attack of intussusception. This occurred in an infant five months 
of age. After the operation the infant was placed on the mother's 
breast again, and had a return of the former symptoms — constant 
colic, green curdy movements, alternating at times with slight diar- 
rhoea. It was taken off the breast immediately, placed on an artificial 
substitute, and throve. 

MIXED FEEDING. 

Mixed feeding is the administration of the breast, supplemented 
by the bottle containing some substitute for the milk lacking in the 
breast. Infants who are nursed on an inefficient breast as regards 
quantity of milk should be carefully weighed, and the quantity of 
milk in the breast estimated for the twenty-four hours. This may 
be done by weighing the infant before and after each nursing, or 
can be roughly estimated by simply observing the amount of milk 
that can be pumped off from both breasts combined two hours after 
a feeding. Having measured the milk, we can estimate within cer- 
tain limits the amount of milk which such a breast would yield in 
twenty-four hours. If there is sufficient milk in the breast for even 
two nursings, the mother should not be denied the pleasure of nursing 
her infant. We should not hastily reject such a breast as worthless, 
for two feedings of breast milk will be a great aid to the infant, 
both in the development of bone and the other tissues of the body. 
If two nursings exist in the breast, we would give the bottle six 
times in the twenty-four hours to an infant below the age of three 
months, and ^.ve times in the twenty-four hours to an older infant. 

In feeding on the bottle in combination with the breast, we should 
begin as we. do in the newborn, with a low percentage of fats and 
proteids. Having accustomed the infant to the bottle, we should 
gradually work up to the normal percentage of fats and proteids, as 
will be shown in the chapter on the Feeding of Infants. The details 
as to the construction of the food are the same as those followed out 
with the infant fed upon the bottle exclusively. 

Care should be exercised in these cases to avoid overfeeding. 
Mothers are especially prone to overfeed infants, having an idea that 
a fat baby is a healthy one ; but if it is explained to the mother that 
fat does not mean health, overfeeding may be avoided. This is 
especially true of mixed feeding; such infants are apt to be overfed 
and to be overweight, for the mother who has two nursings of the 
breast will be apt to consider this of very little moment and attempt 
to feed on the bottle, as if the infant had nothing from the breast at 
its disposal. The result is that such infants frequently suffer from 
overflow vomiting. In many cases this overflow vomiting does not 



ARTIFICIAL FEEDING OF INFANTS. i'66 

seem to disturb the infant to any appreciable degree. It should be 
avoided, however, for such vomiting may at any time become a matter 
of serious moment. 

ARTIFICIAL FEEDING OF INFANTS. 

Artificial feeding of infants is the substitution for the breast milk 
of some one of the foods considered in the previous pages. Although 
attempts have been made to rear infants artificially on asses' or goats' 
milk, the experiment has failed, and cows' milk is universally utilized 
as a substitute for the mother's breast in artificial infant-feeding. 

Before cows' milk can be given to the infant as a food it must be 
modified, that is, the fats, proteids and sugar must be rearranged 
and diluted into an easily assimilable mixture. 

There are two methods now well recognized of modifying cows' 
milk for infant-feeding. One of these methods is the so-called labora- 
tory method of infant-feeding. The laboratory method or Botch's 
method of infant-feeding attempts to recombine the fat, proteids, and 
sugar of milk not only in proportions which conform to what is found 
in human milk, but to attempt to find out, by the frequent changing 
of these constituents, what is best adapted to each infant. Botch 
and his school contend that what is good for or adapted to one infant 
may not be suitable for another. In his own words : " What is one 
infant's food may be another's poison." The Rotch method of 
infant-feeding has now had a very extensive and thorough trial. Its 
successes and failures will be considered later on. The difficult cases 
of infant-feeding baffle the most skilful efforts at modifying cows' 
milk. It is fallacious to assume that the proteids and fats of cows' 
milk can be assimilated without change in the economy. 

The old methods of infant-feeding considered simply the dilution 
of the whole milk two or three times, either with simple water or with 
some decoction of a cereal, either barley or arrowroot. In the first 
month the milk was diluted one in three ; in the second month, one in 
two ; in the third month, two in three, etc. These simple methods 
continued in use until Biedert, in Germany, and Meigs, in the United 
States, attempted to proportion the casein, fat, and sugar so as to 
make the mixture approach the composition of human milk. Biedert 
called his food a cream mixture. It was made in the same general 
way as Meigs' mixture. There was a low percentage of proteids, and 
a fat percentage corresponding to what is found in human milk. The 
proteids in Meigs' mixture ranged from 1.2 to 1.5 per cent. In 
Biedert's mixture the proteids existed to the extent of 1 per cent., t'ar 
2 to 2.5 per cent., sugar 1 per cent. Meigs' mixture contains 3.5 per 
cent, of fat and 6 per cent, o( sugar. 



134 



NUTRITION AND INFANT FEEDING. 



Biedert's Mixture. — Biedert took 50 ounces of milk, or 1.5 litres, 
and allowed it to stand one hour. The cream taken off the top of 
this milk contained 10 per cent, of fat. The amount of cream was 
8 ounces. In other words, the top 8 ounces off 50 ounces of milk 
was a 10 per cent, top cream. It will be seen from this that his top 
milk method is identical with that now in vogue in this country. 
With this he constructed the following formulae. 



Number of 
mixture. 


Cream (10 
per cent.). 


Water. 


Milk-sugar. 


Milk. 


Casein. 


Fat. 


Sugar. 




Litre. 


Litre. 


Grammes. 


Litre. 


Per cent. 


Per cent. 


Per cent. 


I. 


1 


3 

"8 


18 




(=1.0 


2.5 


5.) 


II. 


i 


3 

"8 


18 




(=1.4 


2.6 


5.) 


III. 


I 


f 


18 


V 


( = 1-5 


2.6 


5.) 


IV. 


. i 


I 


18 


\ 


(=1.8 


2.8 


5.) 


V. 


I 


3 


18 


3 
8 


( - 2-1 


2.3 


5.) 


VI. 




I 


12 


1 
2 


( - 2.3 


2.4 


5.) 



If we compare these formulae with Meigs' mixture, we find that 
Meigs contended that the infant needed through its whole nursing 
period practically one formula. 

Meigs therefore had: 



1. A 16-ounce top milk [7 to 8 per cent, of fat]. 

2. A solution of milk-sugar, 15 per cent. 

3. A solution of lime-water. 



He combined them as follows : 

f 3 ounces of top milk. 
8 ounces \ 3 ounces of sugar solution. 
( 2 ounces of lime-water. 

This, according to our present methods, would give approximately 
a mixture of 3 per cent, of fat, 1.3 per cent, of proteids, 6 per cent, 
of sugar, which is also what Meigs strove for, with the exception 
that in some milks, as has been shown, more fat would be obtained 
than that given above, which is calculated from an average milk. 
With some milks Meigs obtained 4.7 per cent, of fat. To be more 
concise, Meiers designed the above method to obtain : 



Water 87.6 "j 

Fat _ 4.7 

Casein 1.1 |> Meigs' artificial food. 

Sugar 6.2 

Salts 0.2 J 

It will be seen from the standpoint of to-day that both these men 

were pioneers of percentage feeding. It may be mentioned here that 



ARTIFICIAL FEEDING OF INFANTS. 135 

the method of Escherich is based on an attempt to calculate with 
rough dilutions of milk the amount of albumin necessary for the 
daily maintenance of nutrition. So far as the author knows, the 
Escherich method is little in vogue in America. 

The other two methods of modifying milk, which calculate the 
gross amount of calories necessary to maintain nutrition for infants, 
are the Huebner-Hoffman and the Soxhlet method. They have en- 
deavored to construct a chemical mixture with the aid of cows' 
milk which is equal to the raw nutritive calories in mother's milk. 
In both these methods the milk is diluted with an equal amount of 
water. Huebner-HofTman uses as a diluent a 6 per cent, solution of 
milk sugar whereas Soxhlet uses a 9 per cent, solution. The addition 
of sugar of milk is intended to take the place of fats, which are de- 
ficient in these mixtures. Sugar of milk, according to Soxhlet, has 
a caloric value equal to that of the fat deficit. 

If it is desirable to feed a great number of infants in a public 
laboratory, I can say from actual experience that these mixtures are 
of the greatest utility, inasmuch as they can be easily prepared, and 
certainly the greater number of infants thrive on them. It is almost 
impossible in a laboratory intended for the use of the poor of a 
great city to give each child a percentage mixture. In other words, 
the feeding en masse is an entirely different problem from the feed- 
ing in private practice. 

Infants from the first to the third month do not thrive as well 
on the Huebner-Hoffman and Soxhlet mixtures as they do on modifi- 
cations obtainable by the home method, which will be described. In 
other words, infants below the third month get in these mixtures an 
excess of proteids and deficiency of fat. The Meigs' mixture is more 
applicable to these cases. 

The Rotch Method. — The method of Eotch has as its pivotal 
point the fact that all infants cannot be fed on the same mixture, and, 
taking the composition of human milk as a working basis, each infant 
should be considered as a separate problem in constructing a formula 
which within certain limits would be most suitable to its needs. 
Rotch therefore separates the milk from the cream by means of a 
separator or by gravity, and working with skimmed milk and cream 
containing 16 or 20 per cent, of fat and a dilution of milk-sugar, the 
constituents of the milk are rearranged. By this method an infant 
can be fed on a mixture of 1.5 per cent, of proteids, 3 per cent, of fat, 
and 6 per cent, of sugar; or 1.5 per cent, of proteids, 2.5 per cent, 
of fat, and 6 per cent, of sugar, or any percentage of proteids, fat, 
and sugar that we may desire to give. Rotch also contends that an 
infant which may not thrive on 1.2 per cent, of proteids might do so 
on 1.5 per cent. The proportion of fat may be reduced or increased 






136 NUTRITION AND INFANT FEEDING. 

as needed in the individual case. In other words, the physician 
should consider his percentage formula in feeding the infant, just as 
he prescribes a certain strength of a drug. 

To obtain these percentages a laboratory is needed, and to-day 
laboratories for supplying these mixtures to be used in the percent- 
age feeding of infants are to be found in large cities. Though 
theoretically this method of reconstructing the milk would seem on 
the surface to be the most rational, it has certain inherent defects. 
These defects are much the same as those of the older methods. 

1. By simply rearranging the proteids, fat, and sugars we do not 
change the proportionate relationship which the casein or caseinogen 
bears to the lactalbumin and other proteids of the milk, and we do 
not in any way change the foreign nature of these to the human 
economy. 

2. "With the exception of a few limited facts and formulae we 
have no data which, with our present knowledge, will enable us to 
know in every case when to increase or to diminish the proteids and 
also the fats. 

3. The process of separating the cream from the milk by ma- 
chinery destroys the original delicacy of the fat-emulsion in the milk. 
The infant does not assimilate these mixtures in every case as well as 
those which are constructed from milk which has not been manipu- 
lated to the extent that laboratory milk has. 

In order to utilize the Rotch method by means of the laboratory, 
the physician has simply to prescribe the percentages that he re- 
quires on a slip made out for the purpose and furnished by these 
laboratories. It is needless to say that unless a physician is satis- 
fied to follow a routine common to all his cases, instead of trying to 
understand, the needs of each infant, he is certain to meet cases 
which even the most accurate modifications of the laboratory will 
not cause to thrive. In other words, the laboratory alone will not 
enable the physician to feed infants successfully. To do this he 
must know not only the percentages required at certain ages from 
constructed formulae, but must study the digestion of each child, its 
movements, and try to analyze whether certain elements of the milk 
such as the fats are in excess or in diminished quantity. It may be 
said that in practice children can get along on a very few fixed 
formulae. An infant which will not thrive on these formulae within 
certain limits will not thrive on any percentage modification of cows' 
milk, no matter how we may rearrange the percentages of its in- 
gredients. 

Principles Underlying the Rotch Method of Percentage Feeding. — 
As has been intimated, we must distinguish very carefully between 
infants who are quite normal and those suffering from intestinal dis- 



ARTIFICIAL FEEDING OF INFANTS. 137 

turbances in feeding thern with cows' milk. The healthy infant 
needs "but very few changes of formulae throughout its infant life. 

The first fact to be ascertained is whether the infant is capable 
of digesting cows' milk at all. If such is the case, by a careful be- 
ginning and modification of milk we can carry the infant along on 
very few formulas, possibly three or four, through its period of infancy. 

Proteid. — The total amount of proteids in the cows'-milk mix- 
tures must be very low for the newborn infant, certainly not to 
exceed 1 per cent, during the first week. After this the proteids are 
increased or kept at this point until the third month, when they 
are increased to about 1.5 per cent., and we may increase them until 
the ninth month. For vigorous infants of heavy weight we may 
increase the proteids at the sixth month to 2 per cent. 

Fats. — The fats in the first days after birth should be low — 
from 1.5 to 2 per cent. After the second week to the third month 
we may give from 2.5 to 3 or 3.5 per cent, of fat; rarely more than 
this. The reason for this is that during this period the infant will 
not digest more fat. Infants who are getting a larger amount of fat 
than the percentage indicated will, as the nurse puts it, frequently 
" spit up " curds between the feedings. All the movements will be 
frequent, soft, and in some cases even of an oily consistence or soapy 
in look and constipated. In other words, infants who are taking 
a greater proportion of fat than that indicated will have a mild fat- 
diarrhoea, which may at any time become more severe and give rise to 
considerable concern. From the third month to the termination of 
infancy the fats may range from 3 to 3.5 or even 4 per cent. ; never 
more than this. Infants who are taking high percentage fat mixtures 
will increase in weight, up to a certain point apparently thriving, 
and then will be noted to become pale, with constipated, dry, formed 
movements. 

Sugar. — In modifying milk the sugars are placed in the mix- 
ture at a uniform percentage of 6 per cent. It is rare for us to be 
called upon to alter this percentage to any considerable extent. Too 
much sugar will cause in some cases fermentation in the gut, result- 
ing in the production of gas. The children may thrive for a time 
on an excess of sugar ; but in all these cases, sooner or later, a point 
is reached at which the sugar is no longer tolerated in large percent- 
ages. It is therefore unwise to give a larger percentage of sugar 
than that indicated. 

Salts. — The salts of the cows' milk are scarcely considered in 
modifications. We know very little to-day about the fate of the 
salts in the cows' milk — how much of them are absorbed and exactly 
how much rejected by the intestine. It has been intimated in an- 
other paragraph that the healing of the milk causes a complete loss 



138 



NUTRITION AND INFANT FEEDING. 



to the economy of the salts present in cows' milk ; but inasmuch as the 
heating of milk is coming more and more into disuse, and more pro- 
nounced efforts are being made to obtain a pure milk which can be 
administered with as little heating as possible, we have still to learn 
the fate of the salts in sterilized, Pasteurized, or raw milk, and the 
indications for adding equivalents of soluble salts to the milk for the 
feeding of infants. 



A Schedule of Percentages Adapted to Infants of Various Ages. 


Age. 


Proteids. 


Fat. 


Sugar. 


Premature infants . 

One to seven days 

Seven to fourteen days 

Fourteen to thirty days 

One to three months 

Three to six months 

Six to nine months 

Nine to twelve months 


Per cent. 
0.33 
0.50 
0.80 
1.00 
1.25 
1.50 

1.50 to 2.00 
3.05 


Per cent. 
1.00 
1.50 
2.50 
3.00 
3.75 

3.00 to 4.00 
3.00 to 4.00 
4.00 


Per cent. 
5 to 6 
5 to 6 
5 to 6 
5 to 6 
5 to 6 
5 to 6 
5 to 6 
5 to 6 



Number of Nursings, with the Quantity of Milk Necessary for 
the Infant. — The quantity of milk which should be given to the 
infant at each feeding from birth to the ninth month has been 
variously estimated. The capacity of the stomach alone would be a 
crude and most unscientific standard, for this would not, in artificial 
feeding at least, follow nature's method with breast-feeding, for from 
birth the amount of milk furnished to the infant by the human 
breast daily does not always accord with the full capacity of the 
infant's stomach. It will be found that the quantity fed to the 
breast-fed infant is much below the stomach capacity if the infant is 
fed at frequent intervals, and, as has been shown in Ahlfeld's baby, 
equal to or even above it if nursed at long intervals. With artificial 
feeding, moreover, we know that there is a great waste in feeding 
infants upon cows' milk, and were an infant fed on exactly the same 
amounts of modified cows' milk as some of the breast-fed infants 
obtain from the breast, it would not increase regularly in weight and 
might even starve. 

The age of the infant, also, is not a guide, for what would be 
a sufficient amount for one infant might not be sufficient for an- 
other, or might be even an excess. In all cases the capacity of 
digestion must be taken into account, and also the development of 
the child. Some vigorous infants will take more food than other 
infants of the same age that are not as well developed physically. 
More rational is the method of arriving at the amount to be given 
at each feeding which takes into consideration not only the capacity 



ARTIFICIAL FEEDING OF INFANTS. 1 39 

of the stomach, but the age and the amount of primary food ele- 
ments necessary to maintain nutrition and to increase body-weight 
of the infant at various ages. If we calculate the amount of 
albumin or proteids or fat necessary per kilogramme of the body- 
weight to maintain nutrition, we shall have the more scientific 
method of determining the quantity of milk to be taken daily by 
the infant. This method has been advocated by Huebner and Rubner 
and also Escherich. 

The difficulty of calculating what is known as the calories neces- 
sary to the maintenance of nutrition and body-weight — and by calories 
is meant the amount of albumin or proteids, fat, salts, and water 
mentioned above — is, that the physician cannot always have at his 
disposal a method by which these calculations can be made. In 
other words, they must rely on investigations made by others, and 
understand that the results as they are presented to us to-day in 
infant-feeding are based on actual calculations of the amount of 
calories necessary to the infant. It has been found that the nutrition 
of artificially fed infants cannot be maintained by an amount of 
proteid of cows' milk equal to that taken in the breast milk. In other 
words, the proteid equivalent can be obtained, but other constituents, 
such as fat, would be at fault, as well as the daily quantity of food, 
were we to depend entirely upon the caloric method. The figures 
given to the student and physician to-day, therefore, are a combination 
of what has been found empirically to be needed, and what has been 
verified in the chemical laboratory to be absolutely necessary. Let 
the student therefore study the amount of breast milk consumed by 
the infant in the twenty-four hours, and compare these amounts with 
the amounts consumed by the bottle-fed infant in the same period of 
time. 

Number of Nursings Daily and Quantity of Each Feeding for 
the Artificially Fed Infant. — If we now attempt to apply the knowl- 
edge acquired in the study of the breast-fed infant to the artifi- 
cially fed infant we meet with the following obstacles: Cows' milk 
taken in the same quantities, as has been said, is not as completely 
used up by the gut as breast milk. There is much more waste, 
as has been shown by Knopfelmacher and Camerer. This waste is 
caused chiefly by the failure of the gut to assimilate completely 
the casein and the fat of the cows' milk. The stools, also, of bottle- 
fed infants are more numerous and of greater total bulk than those 
of breast-fed infants. In view of the lack of definite knowledge 
on all these points, the quantities of modified cows' milk which 
should be given at each feeding to the infant are still, as has been 
intimated, only approximate. The amount of calories necessary for 
the maintenance of nutrition and a definite increase o( the body- 



140 



NUTRITION AND INFANT FEEDING. 



weight will be shown elsewhere, and the student may compare the 
tables given with the equivalent calories in the total amount of breast 
milk and cows' milk given to the breast-fed or artificially fed infant. 
He can therefore satisfy himself of this fact that the older authors, 
and even some of the most recent writers, underfeed their infants, if 
the food which they prescribe is strictly adhered to in quantity and 
composition; and such is the fact, for many of these infants I found 
by observation not only to be underweight, but in some cases they 
fail in complete assimilation of their foods. The physician must also 
understand, however, that only a few of these formulas and state- 
ments really epitomize the limit of our knowledge to-day, and future 
investigators must complete that knowledge. 



Table Showing the Number of Feedings and Quantities of Modified 
Milk to be Given to Artificially Fed Infants. 



Age. 



First day 

Second dav 

Third day 

Fourth day 

Seventh day 

Second week 

Fourth week or first month 

Two months 

Three months 

Four months 

Five months 

Six months 

Seven and eight months . 
Nine months 



Number of feed- 
ings daily. 



3 

8 

8 

8 
8-10 
8-10 
8-9 
7 or 8 

7 

7 
6 or 7 

6 

6 

6 



Quantity at each 
feeding. 



C.c. 

10 

20 

30 

40 

50 

60 

60 

90 

120 

150 

180 

210 

240 

250 



Oz. 



Total to be given 
in 2-4 hours. 



C.c. 



Oz. 



30 

160 

240 

320 

400 

480 

480 

630-720 

840 
1050 
1080-1260 36-42 
1260 42 
1440 48 
1500 50 



1 

5* 

8 

10f 
13£ 
16 
16 

21-24 
28 
35 



The increase in the amount of milk from the seventh to the ninth 
month is not so apparent, since at this period we, as a rule, begin to 
feed cereals in addition to the milk. 

The above figures are not absolute, but only approximate. Some 
infants may require a half-ounce or more than the quantities indi- 
cated ; others will be satisfied with less nursings. In all these items 
an observant student of the infant will, guided by the observations of 
the nurse of the infant, discover the indications in each case for 
himself. 

Household Modification of Milk for Infant-feeding. — The accu- 
racy obtained in home modification is as well adapted to the feeding 
of infants as the laboratory percentages. The advantages of home 
modification of cows' milk for infant-feeding may be stated briefly 
as follows : The family and the physician can be independent of the 
modifier at the laboratory. The milk is manipulated as little as 



ARTIFICIAL FEEDING OF INFANTS. 



141 



possible. If the infant does not thrive, we can say definitely what 
is at fault. 

The home modification of milk for infant-feeding depends on the 
fact that in large cities, and in places where milk is obtainable from 
the dairy within a reasonable time, the milk can be separated by 
gravity into top milk or cream and skim milk, and this separation 
takes place in certain definite proportions. Meigs, Biedert, and 
Chapin showed that it is possible to construct from top milk per- 
centage mixtures, inasmuch as the top milk prepared in the manner 
to be described has an average constant percentage of fat, proteids, 
and sugar. 

Fig. 25. 



QUART BOTTLE OF MILK 
BEFORE CREAM HAS RISEN 




QUART BOTTLE OF MILK 
AFTER CREAM HAS RISEN 



GRAVITY CREAM 

CONTAINS 10* TO 24* 




FAT IN DIFFERENT PORTIONS 

REMOVED FROM THE TOP 

AND MIXED. 



TOP 2 OZS. MIXED 24* FAT 



REMAINING MILK 

OR 

SKIM MILK 

FAT .5* TO 1.5* 

PROTEIDS 3* TO 42 
SUGAR 4£ TO 6* 



4 3 OZS. ■' 


22.5* " 


' 4 OZS. " 


21.4* " 


' 5 OZS. " 
* 6 OZS. " 

7 OZS. " 
1 8 OZS. " 
' 9 OZS. " 

10 OZS. " 


19.2*" 
16.8*" 
15.0?" 
13.3* " 
11.52 " 
10.52 " 


12 OZS. ■« 


9.0* " 


14 OZS. " 


7.82" 


16 OZS. " 


7.02 " 


18 OZS. •■ 


6.3*" 


20 OZS. " 


5.02" 


22 OZS. » 


6.42 " 


24 OZS. " 


5.02 " 


26 OZS. '■ 


4.7* " 


28 OZS. " 


4.5* " 


30 OZS. '« 


4.32 n 


ALL MIXED 


4.1* " 



Diagram illustrating the formation of top milks in quart bottles, so-called setting process. 
Modified from the diagrams of Chapin. 



Top Milk. — In this country the custom of delivering milk in 
so-called quart bottles is almost universal. The milk is placed in 
these bottles at the dairies, and when it reaches the consumer, it is 
set, as it is termed, into a top creamy layer above, and a milk poor 
in fat, so-called skim milk, below (Fig. 25). 

In the supernatant creamy fluid, or top milk, we find certain 
definite percentages of fat. In modifying milk in the home, the top 



142 NUTRITION AND INFANT FEEDING. 

layer as it separates from the milk is utilized as it is delivered in 
quart bottles. Chapin has found that if a number of milks deliv- 
ered in the city homes are analyzed, the first 9 ounces from the top 
of the quart bottle of milk will contain all the way from 12 to 16 
per cent, of fat, varying with the richness of the milk in fat. 

Twelve Per Cent. Top Milk. — If the original milk contains 4 per 
cent, of fat, the first 9 ounces will be what is known as a 12 per 
cent, top cream. If the milk is a very rich milk containing butter 
fat to the extent of 5 per cent., the top 9 ounces will contain 16 per 
cent., approximately, of fat. The proteids are quite constant in the 
top milk and are equal to those found in the skimmed milk. In 
other words, in milk rich in butter fats the top milk contains fat in 
proportion to the proteids of 3 to 1. If the milk is poor and only 
contains 3 per cent, of butter fat, the first 9 ounces will contain 
generally 9 per cent, of fat, and this milk will contain 3 per cent, of 
proteids, so that the percentage of fat to proteids still remains 3 to 1. 
It may be said at the start that the student would do well not to 
consider the thin milk as existent, for most milk, either in the city or 
throughout the country, contains at least 4 per cent, of butter fat. 

Seven Per Cent. Top Milk. — Another top milk to be considered is 
the so-called first 16 ounces taken from a quart of milk. If the milk 
is a rich milk and contains 5 per cent, of butter fat, the first 16 ounces 
will contain 9 per cent, of fat. If it contains 4 per cent, of butter 
fat, the first 16 ounces will contain 7 or 8 per cent, of fat. The fat 
in both of these instances is present in a proportion of 2 to 1, as com- 
pared to the proteids. The physician would do well to assume in 
making his modifications that he is dealing with a rich milk. In 
this way he will avoid giving mixtures which contain too much fat, 
which element gives the most trouble if present in too great quantity. 
If the student will therefore simply consider the top 9 and 1 6 ounces 
of rich milk, he will have sufficient material for feeding the infant 
up to the ninth month of infancy. He should therefore try to per- 
fect himself in the methods of utilizing top milk in which the fat 
is present, as compared to the proteids, in the proportion of 3 to 1, 
and a more dilute top milk in which the fat is present, as compared 
to the proteids, in the proportion of 2 to 1. 

In feeding infants up to the third month it is convenient to use a 
top milk in which the fat is present, as compared to the proteids, in 
the proportion of 3 to 1. In other words, it is best to use the first 
9 ounces of top milk, for by this method we can obtain, as will be 
shown by the tables, a smaller percentage of proteids and the requisite 
percentage of fat indicated in the earlier periods of infancy. From 
the third to the sixth month it is advisable to use a top milk in which 
the fat is present, as compared to the proteids, in the proportion of 



ARTIFICIAL FEEDING OF INFANTS. J 4:i 

2 to 1, for in this way we can obtain a larger percentage of proteids 
and more fat from one bottle of milk than we could if we use a 
smaller amount of richer top milk in which the fat is present, as 
compared to the proteids, in the proportion of 3 to 1, for in the latter 
case we shall be compelled to use 2 bottles of milk. This can more 
readily be understood by reading the subjoined tables indicating the 
percentages at the various ages. 

Chapin, for the purpose of obtaining the top milk, has devised a 
small dipper. The use of the dipper is convenient but not necessarily 
essential. If the top milk is poured off carefully, equal accuracy is 
obtainable without the use of the dipper. 

Top Milk Made at Home. — In cities milk is delivered in quart 
bottles, and in many places in the country this is also the case. But 
if the practitioner is living in a district where bottled milk is not 
sold or not obtainable, it is quite necessary that he should understand 
that there is no mystery about bottled milk. Any milk obtained 
shortly after milking and placed in a wide-necked bottle or utensil 
with a capacity of one quart will separate the top milk, or set, as it 
is called, in the manner previously described under the heading of 
Top Milk. This setting process takes place within four hours after 
the milk is placed in the utensil, so that, if the practitioner has not 
access to bottled milk, he can be accurate if he will obtain an ordinary 
quart utensil, such as a pitcher, and place the milk in the same as 
soon after the milking as possible, setting it aside for four to six 
hours, and then proceeding according to directions given. Such milk 
will show the separation into the skim milk and creamy layer, as 
described elsewhere. 

There should be no visible dirt or dark specks in the bottom of the 
bottle, for such milk is unwholesome and should not be given to the 
infant. The milk should have no peculiar odor, for no matter how 
carefully modified, such milk Will be rejected by the infant. If 
mixed with equal portions of 70 per cent, alcohol, milk when heated 
in a test-tube should not curdle. In other words, we should begin 
with a good, fresh, clean milk. 

The Home Preparation or Modification of Milk for Infant 
feeding". — In what follows it must not be forgotten that the formulae 
and statements are directed toward the management of distinctly nor- 
mal cases. We will consider the percentage modification of cows' 
milk in the household, presupposing that there are no difficulties in 
the way of complete assimilation by the infant. 

The Method of Calculating Percentages. — Taking the milk in 
quart bottles as a standard we know that in the first 9 ounces of top 
milk the ratio of fat to proteids is as 3 to 1, and in calculating any 
percentages, whether we fix on the proteids or on the fats as a method 



144 NUTRITION AND INFANT FEEDING. 

of calculation makes very little difference, provided we remember 
this proportion. For example: If we calculate on a formula con- 
taining 3 per cent, of fat, and we desire to construct this formula 
with the first 9 ounces of top milk, the proteids in that formula will 
be 1 per cent. If we wish to give 0.25 per cent, proteids from the 
first 9 ounces of top milk, the fat must necessarily exist in a per- 
centage of 0.75. It is well, therefore, for the practitioner simply to 
fix in his mind what percentage of one or the other ingredient he 
desires to give to the infant, calculate upon that, and the fat or pro- 
teid will exist in that formula in the ratio indicated. The author, 
for convenience, fixes the amount of proteid which he wishes in his 
mixture, multiplies that by 3, to obtain the percentage of fat that 
would exist in that mixture, and proceeds in the following way : An 
infant at birth, for example, will receive 0.5 per cent, of proteids, its 
fats would be 1.5 per cent., if constructed from the first 9 ounces of 
top milk. 

Let us suppose, for example, that a 12 per cent, top milk is to be 
used, and that the total amount to be given in twenty-four hours is 
8 ounces. We wish to reduce the percentage to 1.5. The question 
involved is, "How much of the 12 per cent, top milk must be used 
to make a 1.5 per cent. 8-ounce mixture?" The following mathe- 
matical statement simplifies the process : 

If of a 12 per cent, top milk you would use 8 ounces in twenty- 
four hours, to make a 1 per cent, top milk you would use A of 8, 
equal f ounces. To make a 1.5 per cent, top milk you would use 
1.5 times f, equal 1 ounce. 

One ounce, then, of a 12 per cent, top milk, diluted 7 times, will 
give an 8-ounce 1.5 per cent, mixture. 

How to Work Out the Above Percentages of Fat, Proteids, and Sugar. 
— Problem 1. — Let the physician take, for example, a premature 
infant. By referring to the schedules it is seen that such an infant 
should have 10 or 12 feedings in the twenty-four hours. The most 
assimilable mixture should have a strength of 0.33 per cent, proteids, 
1 per cent, of fat, and 5 or 6 per cent, of sugar. Such an infant 
should have 12 feedings, each -J ounce, making a total of 6 ounces 
for the twenty-four hours. If a 12 per cent, top milk is utilized, 
inasmuch as the fat-percentage of our mixture is 1 and that of our 
top milk is 12, the total quantity in the twenty-four hours being 6 
ounces, we need tV of 6, equal -J ounce of this 12 per cent, top milk, 
which must be diluted by 5 -J ounces of water or barley-water, as the 
case requires, in order to obtain a mixture of 6 ounces containing 1 
per cent, of fat. 

In order to get the requisite percentage of sugar of milk which, 
when mingled with the diluent and the -J ounce of top milk, will 



ARTIFICIAL FEEDING OF INFANTS. 



145 



approximate 5 per cent., 2 teaspoonfuls of sugar of milk should be 
dissolved in the diluent before adding the top milk. 

Problem 2. — The infant is one month old. Such an infant would 
assimilate best a mixture approximating 1 per cent, of proteids, 3 
per cent, of fat, and 5 per cent, of sugar. It would need 10 feedings 
in the twenty-four hours, each containing 2^ ounces, making a total 
quantity of 25 ounces. If the 9-ounce top milk is used (12 per cent, 
of fat) we would proceed as follows : The percentage of fat desired 
being 3, and the total daily quantity being 25 ounces, we would have 
to take A of 25, equal to 6J ounces of 12 per cent, top milk, with 
18f ounces of the diluent, which should contain 6 per cent., of milk- 
sugar, or 7 teaspoonfuls. 

Problem S.— The infant is four months old, and it is desirable 
to construct its formula from the 16-ounce top milk (7 per cent. 
fat), ratio of fats to proteids 2 to 1. The percentages most adapted 
at this age would be 3 of fat, 1.5 of proteids, and 5 of sugar of milk. 
This infant should have 8 feedings in the twenty-four hours, each 
containing 5 ounces, a total of 40 ounces of food in the twenty-four 
hours. The percentage of fat being 3, that of the top milk 7, and 
the total amount of food being 40 ounces, there would be needed % of 
40, equal to 17 ounces of top milk, with 23 ounces of the diluent, to 
which is added 6 per cent, of milk-sugar, or 9 teaspoonfuls. 

For the above formula it will be necessary to use 2 bottles of milk, 
taking 16 ounces off each, mixing them together, and of these 32 
ounces to utilize 17. 

Problem J/-. — The infant is six months of age, and would need 7 
feedings, of 7 ounces each, making a total of 49 ounces for the twenty- 
four hours. The formula most adapted in this case would be 3 per 
cent, of fat, 1.5 per cent, of proteids, and 5 per cent, of sugar of 
milk, utilizing the top 16 ounces of a bottle of milk, the percentage 
of fat in the formula being 3, that of the top milk 7, and the total 
amount of the food being 49 ounces, there would be needed % of 49, 
equal to 21 ounces of top milk ; 28 ounces of the diluent will be neces- 
sary, containing 5 per cent, of milk-sugar, or 9 teaspoonfuls. 

It will be necessary in this case, also, to utilize two quart bottles 
of milk to obtain 21 ounces of 16-ounce or 7 per cent, top milk. 
That is, 32 ounces of this top milk are obtained, and of these 21 
ounces only are utilized. 

Problem 5. — The infant is nine months of age. In this case 6 
feedings will be given in the twenty-four hours, each containing S 
ounces, making a total of 48 ounces. The formula most adapted to 
this age would be 4 per cent, of fat, 2 per cent, of proteids, and 5 per 
cent, of milk-sugar. The percentage of i'al being I in the formula, 
that of the top milk 7, and (lie tot al quantity o( (ood for the twenty- 

10 



146 NUTBITION AXD IXFAXI FEEDIXG. 

four hours being 4S ounces, the physician would need 4 t of 48, equal 
to 25 ounces of 7 per cent, or 16-ounce top milk, 23 ounces of the 
diluent, and enough sugar of milk to make a 5 per cent, solution. 

Problem 6. — An infant six months of age, for therapeutical rea- 
sons, is to be put on a formula containing 1.5 per cent, of fat, 0.5 
per cent, of proteids. and 5 per cent, of sugar. Here the percentage 
of fats to the proteids is as 3 to 1. therefore it Trill be convenient to 
use the top milk containing 10 to 12 per cent, of fat and 3. 5 per cent, 
of proteids. It is desired to give the infant 7 feedings of 7 ounces 
each, making a total of 49 ounces. The percentage of fat being 1.5 
in the formula, and that of the top milk being 12. the total quantity 
for the twenty-four hours being 49 ounces, the physician would need 

1.5 

' of 49, equal to 6t ounces of top milk, 42 J ounces of the diluent. 

In order to get a 5 per cent, solution of the milk-sugar there would be 
needed in this case 5 per cent, of 42 ounces, equal to 18 teaspoonfuls 
of the milk-sugar. 

It frequently happens with infants above three months of age 
taking a modification of the 16-ounce top milk that constipation will 
set in, and we wish to increase the fats in order that the movements 
may be less constipated. In order to do this we must obtain a top 
milk which is richer in fat than the top milk we are giving. To 
illustrate: The infant who is taking a third dilution of the 16-ounce 
top milk will be taking approximately 2.5 per cent, of fat, 1.2 to 1.5 
per cent, of proteids. If we wish to increase the fats to 4 or 3.5 per 
cent, and retain the proteids we are administering to the infant, it 
will be impossible to do this with the 16-ounce top milk, for any 
dilution of this milk will vary the proteids. TTe are therefore com- 
pelled to resort to the utilization for such an infant of the 9-ounce top 
milk, which contains an average of 10 to 12 per cent, of fat. By 
diluting this one-third we would get about 3.5 to 4 per cent, of fat and 
still retain the same percentage of proteids as in our original mixture. 

An infant four months of age, taking eight bottles, 5 ounces each, 
would need 40 ounces for its daily mixture. TTe would therefore be 
compelled to use, in order to obtain the 9-ounce top milk, 2 quarts of 
milk, from each of which 9 ounces would be taken, making 1 8 ounces 
of top milk. This, after being thoroughly mixed, would be utilized 
to the extent of 13 ounces for our mixture, giving 27 ounces of the 
diluent, whatever that may be. we would have a formula of 3.5 per 
cent, fat, 1.3 to 1.5 per cent, proteids. 

It should be understood that the percentages of fats given in these 
tables are only approximate, for there is no milk which will yield an 
absolute fixed percentage of fat in the top milk obtained by gravity, 
without variation, from day to day. The proteids, however, are 



ARTIFICIAL FEEDING OF INFANTS. 



147 



more constant in percentage; but even here in modification we can 
only obtain approximate accuracy. Though these tables contain 8 
modifications each, some of them differing but \ of 1 per cent, either 
in the fats or the proteids, such minutiae are not really needed or even 



Formulae constructed with top 9-ounce milk, having an average 
composition of 12 per cent, fat, 3.5 per cent, proteids, 4 per cent, 
sugar. Possible combinations. 



Fat. 


Proteid. 


Sugar. 


1.00 per cent. 


0.33 


)er cent. 


5 per cent 


1.50 " 


0.50 


u 


5 


2.00 " 


0.66 


a 


5 


2.50 " 


0.83 


a 


5 


3.00 " 


1.00 


u 


5 


3.50 " 


1.20 


it 


5 


4.00 " 


1.33 


a 


5 " 


4.50 " 


1.50 


a 


5 



Formulas constructed with top lQ-ounce milk, having an average 
composition of 7 per cent, fat, 3.5 per cent, proteids, 4 per cent, sugar. 
Fats to proteids 2 to 1 . Possible combinations. 



Fat. 


Proteid. 




Sugar. 


1.00 per cent. 


0.50 


per cent. 


5 


per cent. 


1.50 " 


0.75 


n 


5 


" 


2.00 " 


1.00 


u 


5 


" 


2.50 " 


1.25 


a 


5 


u 


3.00 " 


1.50 


u 


5 


it 


3.50 " 


1.75 


a 


5 


a 


4.00 " 


2.00 


u 


5 


a 



Whole milk having an average composition of 4 per cent, fat, 3.5 
per cent, proteids, 4 per cent, sugar. Fats to proteids 8 to 7. Pos- 
sible combinations. 



(C 



Fat. 
1.00 per cent. 
1.50 
2.00 
2.50 
3.00 
3.50 
4.00 



Proteid. 
0.85 per cent. 
1,32 " 
1.60 " 
2.15 " 
2.60 " 
3.00 " 
3.50 " 



Sugar. 
5 per cent. 
5 
5 
5 
5 
5 
5 



possible in practice. It will be found best to master 3 or 4 modifica- 
tions of top milk, constructed either from the 9-ounce top milk or the 
16-ounce top milk, and utilize these in general practice. For exam- 
ple: The infant who is taking 1 per cent, of fat and 1.33 per cent. 
of proteids may do just as well on 1.2 per cent, of fat and 1.50 per 
cent, of proteids. For all practical . purposes, therefore, formula 
which contain 1.5, 2.5, and 3.5 per cent, of fat will be as available in 
practice as formulae containing 1, 2, and 3 per cent, of fat. 

Referring to tho proteid percentages, it will be seen that certain 



148 NUTRITION AND INFANT FEEDING. . 

of them are in heavy-faced type. Both in the laboratory and at home 
it is impossible to obtain an accuracy which will assure the physician 
that he is administering to his patient 0.66 and not 0.5 per cent, of 
proteids, or some intermediate figure; nor can he be certain that his 
mixture, even if prepared at the laboratory, contains 1.23 or 1.33 
per cent, of proteids, rather than some slightly higher or lower figure. 
The reason for this is that the proteids of cows' milk, like the fats, 
must vary from day to day, and thus no absolute fixed average per- 
centage of proteids can be counted on. 

Konig, in an analysis of several hundreds of milks obtained from 
a number of herds of cows, shows that the proteid percentages in milk 
vary, not only at different seasons of the year, but at times of the day, 
and also with different kinds of fodder. It is therefore illogical to 
attempt the working out of minutiae of percentages varying from 0.2 
to 0.3, when the original milk has not a fixed average percentage. 
To obtain accuracy within the difference between 0.2 to 0.3 per cent, 
would necessitate a chemical analysis of the milk before each modifi- 
cation is made, a manifestly impracticable procedure, especially as 
regards the proteids in the milk. The author has gone into these 
matters to show that the elaborate tables given by some are, on careful 
analysis, impracticable. It is well, therefore, for the physician to 
feel assured that with the proteids, as with the fats, approximate 
formulas with averages of 0.25, 0.5, 1, 1.5, 2, and 2.5 per cent, of 
proteids are as effective in practice as minute fractional percentages, 
if such were attainable. 

Too High Fat-percentages and Their Remedy. — If Problem 4 
is studied it will be seen that 2 bottles of milk must be utilized in 
order to obtain the requisite 21 ounces of top milk, and if this is so 
for the sixth month, more of this top milk will be required for the 
seventh and eighth months. Some infants will not thrive on such a 
large amount of fat. In the summer especially they will spit up, 
and have several loose movements daily. Or they become anaemic 
and constipated, with dry, soapy movements. In the face of such 
difficulties I follow the plan of using only 1 bottle of milk; and, if 
after the fifth month (Problem 3) more than 16 ounces of top milk 
are required, I take these off the top of the bottle, adding the rest as 
diluent. Thus, at the sixth month, 21 ounces off the top of a quart 
of milk to 28 ounces of diluent. At the seventh month, 23 ounces off 
the top of a quart of milk to the required amount of diluent. At the 
eighth month, 25 ounces off the top of a quart of milk to the required 
amount of diluent. The amount of diluent is calculated as in the 
former tables. 

By this method of simply increasing the amount of milk taken 
off the top of one quart of milk after the sixth month, we arrive at a 



ARTIFICIAL FEEDING OF INFANTS. 149 

point (the tenth or eleventh month) when the infant is taking a full 
quart -of milk with diluent daily. This method, which is exceedingly 
simple, and which in summer particularly does away with the danger 
of excess of fats, has served me well. 

If this method is pursued, the strict calculation of percentages of 
fats and proteids is necessarily abandoned. 

Problem 7.- — Let us suppose that for certain reasons top milk 
cannot be obtained, or the milk obtainable is whole milk and the 
people are not sufficiently intelligent to construct top-milk mixtures. 
In the table of possible combinations with whole milk there is a most 
available formula : 

Two per cent, of fat; 1.6 per cent, of proteids. Whole milk having a strength 
of 4 per cent, of fat. 

7 feedings are needed. 
7 ounces each. 
49 ounces in the whole mess. 

Percentage of fat needed, 2, divided by 4 per cent, in the whole 
milk will result as follows : 

2 sv AC) I 24 ounces of milk, 

T ^ \25 ounces of diluent. 

Problem 8. — Taking the same infant with the same 49-ounce 
mixture to construct the formula : 

Three per cent, of fat; 2.6 per cent, of proteids. We would need: 

3 ^ AC . j 37 ounces of milk, 

* X y — \ 12 ounces of diluent. 

Diluents. — Very little has been said thus far as to diluents in 
modifying cows' milk. The principal function of diluents is to 
dilute or cut up the casein of the milk, and at the same time dilute 
the fat to such a degree as to make both these ingredients more digest- 
ible in the infant stomach. As diluents used in modifying cows' 
milk, a solution of milk-sugar of definite strength, barley-gruel, or 
whey is used. 

Solution of milk-sugar should be 5 or 6 per cent, strength. Milk- 
sugar chemically pure is sold in the shops as such, and it is dissolved 
in water which has been filtered and boiled or in distilled water. 

As to barley-water, the preparation of which is detailed in full 
elsewhere, it should be remembered that the milk-sugar is dissolved 
in the barley-water while it is being boiled, as in this way there is 
no residue. 

Reaction. — Lime-water is added to all milk mixtures in order 
not only to make them more alkaline, but to aid, as has been shown, 
in the digestion of the casein by delaying coagulation of casein in the 
stomach and favoring the passage of the milk or stomach contents 



150 NUTEITIOX AND INFANT FEEDING. 

into the intestine. The food should contain, according to Meigs and 
Rotch, from one-twentieth to one-twenty-fifth of its bulk of lime-water. 

Lime-water is made by adding about an ounce of unslacked lime 
to half a gallon of boiled or distilled water, shaking well, and then 
allowing it to stand until the supernatant liquid is clear. It is then 
ready for use. 

Lime-water is best added to the food just before giving to the 
infant. Thus, to an 8-ounce mixture are added 3 teaspoonfuls of 
lime-water. I generally advise the omission of the lime-water after 
the sixth month of infancy. 

When is a Bottle-fed Infant Thriving? — It may be said that a 
bottle-fed infant is thriving if it increases regularly in weight, wakes 
up betimes to nurse the bottle, does not suffer from colic, and has 
movements of uniform consistence and color. It should not " spit 
up," as it is said, to an inordinate degree. There should be no rejec- 
tion of food after the bottle has been given, thus showing that the 
quantity has been accurately gauged. The color of the infant should 
be good. The young infant should sleep most of the time, except 
when nursing or engaged in play. Older infants should have a 
happy, contented expression of the face. 

We do not consider an infant with a very large deposit of fat as 
necessarily a healthy one. On the other hand, another of exactly the 
average weight may be much healthier than the infant who is over- 
weight. Thus, the physician will have to draw conclusions from 
various data of color, weight, development, and well-being of the 
child as to whether it is thriving on the food mixture. 

Physicians should not be afraid to leave well enough alone with 
the artificially fed infant, and, if the gain during some weeks is not 
up to the standard, should not be discouraged, in view of the fact 
that the succeeding week may show the average gain. Bottle-fed 
infants gain irregularly; sometimes for a week may appear to have 
gained but very little, an ounce or two. The succeeding week may 
show a marked recuperation and gain in weight above the average. 

The physician imbued with the principles of percentage feeding 
also should not be too hasty to change percentages, but should en- 
deavor to content himself with a minimum number of changes. In 
this way the parents of the infant will be impressed with the fact that 
the artificially fed infant is not taking, even at the best, a perfect 
food, but only one which must make up the deficiencies caused by the 
lack of the mother's milk. 

Among the disturbances from which apparently normal infants 
suffer, and by this we refer to infants who are thriving, are, first, 
constipation. The physician will see an infant on one mixture have 
two movements daily, perfect in color and consistence; whereas 



ARTIFICIAL FEEDING OF INFANTS. 



151 



















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152 NUTRITION AND INFANT FEEDING. 

another infant on the same mixture will be inordinately constipated, 
and movements hard, having the form and consistence of scybala. 
He will thus learn to account for this constipation on various grounds. 
A certain percentage of newborn infants are apt to be constipated, 
and this constipation is due to an inherent inertia of the gut, and 
also a lack of secretion of the normal lubricating fluids of the gut. 
In these cases also we may find a tendency to constipation inherited 
from the mother. 

Given an infant with constipation, there are various modes of 
rendering this symptom a matter of less care to the physician, as 
well as to those in charge of the infant. If the food is heated, it is 
well either to omit this process or to reduce the heating to a mini- 
mum. We should endeavor not to give constipated infants steril- 
ized food; but rather, in the winter and fall, Pasteurized or raw 
food. In some cases it is necessary to diminish the amount of 
fat in the mixture, and in this place we should caution the physi- 
cian to go very slowly in increasing the fats. If the fats are in- 
creased we should never, especially with the newborn or young infant, 
give more than 3 to 4 per cent, of fat. In many cases 4 per cent, 
of fat will be followed by other symptoms fully as annoying as con- 
stipation. I refer to the so-called spitting or rejection of part of the 
food after nursing. This consists in the bringing up of a number 
of curds in the intervals between feedings. These curds, as a rule, 
have a sour odor and are accompanied by eructations of gas. In such 
cases it is best to reduce the amount of fat, for in very young infants 
an irritation of the stomach to any marked degree, as evidenced by 
the rejection of a part of the food in the spitting of curds, may result 
in serious vomiting, a symptom much more to be feared than the con- 
stipation. However, in the administration of top milk we very often 
find, especially with the newborn (and by newborn I refer to infants 
below three months of age), that a fourth dilution of top milk replac- 
ing a third dilution will often remedy the constipation. 

Spitting. — Spitting, or rejection of part of the food after nursing 
to any extent, may become an annoying symptom, and the physician 
should try his best to remedy it, although the infant may apparently 
be thriving. A breast-fed infant may spit to quite a degree and not 
cause us any uneasiness; but it is otherwise with an artificially fed 
infant. Such a condition may lead to serious enteric disturbances, 
necessitating a suspension of the food entirely; or the spitting may 
be due in some cases to an excess of fat, and we should try with such 
infants, even though thriving, to reduce the fat gradually until we 
arrive at a point at which the spitting is less evident, at the same time 
retaining the percentage of proteids in the mixture. 

Colic.' — Bottle-fed infants who are apparently thriving and at 



ARTIFICIAL FEEDING OF INFANTS. 1 53 

times quite contented will have one or two attacks of colic in the 
twenty-four hours. In a breast-fed infant we may have a number 
of colicky attacks. The breast-fed child may thrive, the movements 
may not show much change from the normal, and the physician in 
these cases is not disturbed; on the other hand, in an artificially fed 
infant an excessive degree of colic is a cause of uneasiness, not only 
to the family, but to the physician, for it indicates that the digestion 
of the infant does not proceed along physiological lines. It has been 
stated that one or two attacks of colic daily are not inconsistent with 
perfect health in the infant, if the movements are of normal con- 
sistence and color. On the other hand, any excess of colic, combined 
with a disturbance of the consistence and color of the movements, the 
appearance of curd particles or white curds in the movements, or a 
yellow movement containing too much fluid, mixed with white curds, 
is a signal for a change in the percentages of fats of the mixture. 
We should not, however, reduce them to too low a figure. Less than 
1 per cent, of fats for an infant from three to six months of age will 
result in a diminished gain in the weight of that infant, although 
the infant may be thoroughly comfortable. On the other hand, some 
infants at the age of six to nine months may digest 2 or more per 
cent, of fats, so that working between these limits the physician will 
have to find out the amount of fats that can be completely digested 
by the infant, always bearing in mind never to allow the proteids to 
reach too low a percentage, else not only diminished gain in weight 
will result, but also other disturbances of nutrition which we wish 
to avoid. 

Fat-diarrhoea. — The physician, while increasing the proportion of 
fat in his mixture, the infant thriving at the same time, will find 
that the movements will at times become fluid, though yellow in color ; 
and at other times will be more consistent and of the same color. 
With some infants the movements will become of an oily consistence. 
In such extreme cases there will also be uneasiness with the move- 
ments, and colicky attacks. Movements which are normal in color, 
contain no curds, whose consistence is of an oily character, indicate 
that the fats are in excess of the necessary quantity. Such infants 
may even gain in weight on this excessive amount of fat. The food 
should be suspended in these cases for a few hours, and the mixture 
administered with a diminished amount of fat. Such infants will 
do well on low percentages; whereas other infants of the same age 
will take more fat and still give no evidences of fat-diarrhoea. 

Greenish Movements.- Bottle-fed infants, apparently thriving will 
have at times movements which contain green residue and white 
curds, and this will be followed by a movement which is perfectly 
normal in color and consistence. This may be repeated al intervals 



154 NUTRITION AND INFANT FEEDING. 

of a week, and I am accustomed to lay no stress on such an occur- 
rence. On the other hand, if such green movements occur frequently 
and are accompanied by colicky pains, it indicates that the milk is 
not digested. Such infants can scarcely be included in the normal 
category; they are simply mentioned here, and the subject will be 
taken up in another section. 

Disturbances on the Boundary Line between the Normal and the 
Abnormal. — Vomiting.— Some mothers will tell the physician that the 
child vomits a certain amount of its food once or twice daily and does 
not seem to be very much disturbed by it. If such an infant in- 
creases in weight, looks well, and has movements of normal consis- 
tence there is very little indication for our interference, except, 
perhaps, to reduce slightly the amount of food administered at each 
nursing. The cases, however, which puzzle the physician are those 
which vomit 2 or 3 times daily, and which do not increase in weight 
in a physiological ratio. Such infants increase slightly in weight at 
first, and after a time cease to increase. We have then to deal with 
an abnormal condition. 

Too Low a Percentage of Proteids. — It has been mentioned that 
the physician should be cautious not to reduce the percentage of 
proteids beyond a certain limit. If he does, the child will not only 
fail to increase in weight, but the development of the child will be 
below the normal, and we may even incur the danger of scurvy, pro- 
nounced rachitis, and other evidences of disturbed nutrition. 

Too Low a Percentage of Fats. — Too low a percentage of fats will 
also result in disturbed nutrition to the infant. By this we refer to 
a percentage of 1.5 of fat for an infant five months of age. If such 
a percentage of fat is continued for two or three months, the infant 
will cease to increase in weight and will develop those disturbances of 
nutrition already mentioned. 

Assimilation of the Food Without Increase in Weight. — It is not in- 
frequent, especially in the newborn, to find infants who completely 
assimilate the mixture we administer to them. They sleep well, are 
not disturbed by colic, the movements may be constipated or of normal 
consistence and color, and still the infant fails to increase in weight. 
These are the baffling cases. An increase in the percentages for the 
newborn infant, or in the quantity of the mixture, can be made within 
certain limits. If we overstep the bounds, the mixture will disagree 
with the infant and cause symptoms which will necessitate a tem- 
porary suspension of the food. 

When Shall the Food be Peptonized? — It has been mentioned 
elsewhere by the author that in peptonizing the food he makes use of 
only one method — the cold method — for the reason that most infants 
will not object to the taste of the food when this method is employed. 



ARTIFICIAL FEEDING OF INFANTS. 155 

The cases in which an attempt should be made to peptonize the food 
are as follows: The newborn infant is placed upon a percentage mix- 
ture. It suffers from constant colic, sleeps very little, has move- 
ments which are green, mixed with curds; on the whole the infant 
remains stationary in weight or the increase is very slight. 

In these cases most satisfactory results are sometimes obtained 
by peptonizing the food in the following way : Just before the food is 
administered a third or a quarter of a so-called peptonizing tube is 
added to the milk; it is well shaken and heated for two minutes. 
With this exposure to warmth there is very little development of the 
bitter taste in the milk. It is then given to the infant. It is sur- 
prising to see what an immediate change occurs in the general con- 
dition of the infant. The child will sleep, the pain and colicky attacks 
disappear, the movements become yellow in color and normal in 
consistence ; the increase of weight will begin and continue along 
physiological lines. The physician must not expect, however, that 
this result will follow in every case. It is to be supposed that before 
any attempt is made at peptonizing the mixture the physician has 
made every effort to find the correct proportions for his particular 
patient, and having satisfied himself that there is a difficulty in the 
digestion, he may proceed to peptonize the milk, but not under any 
any other conditions. 

Whey Method of Modification of Cows' Milk.— This method is 
really very old. In Routh's " Infant-feeding " we have the whey 
method, similar to that which is practised to-day, described by Mr. 
Lobb. This gentleman, in a brochure on hygiene, read before the 
Harveian Society, gave the details of preparing a " compound resem- 
bling human milk," and this mode of modification of cows' milk as 
devised by Professor Falkland. Recently the method has been taken 
up by Vigier, and elaborated by Monti, of Vienna, in 1897. Rotch 
has advocated this method of diluting milk for feeding infants with 
difficult digestion. 

Whey has a composition, according to Konig of — 

Proteid 0.8 per cent. 

Fat 0.2 " 

Sugar 4.7 

Lactic acid 0.3 

Salts 0.6 

The proteid contained in whey includes the lactalbumin of the milk 
and lactoprotein. The sails are potassium, sodium, lime, ami mag- 
nesium, with iron in combination with chlorine, phosphorus, and sul- 
phuric acid. 

Whey is made by adding 1 part o( rennet to 200 parts of milk 
at a temperature of 35° to 10° C. (95° to 10 1" F.), or a tablespoon- 



156 NUTEITION AND INFANT FEEDING. 

ful of the rennet sold in the shops may be added, roughly speaking, 
to a quart of milk, allowed to stand, mixing thoroughly until the 
milk separates into a liquid and a curd portion. The curd is then 
broken up thoroughly and the whole is strained through cheese- 
cloth. About 20 ounces of whey may be thus obtained from a 
quart of milk. The rennin of the rennet is still existent in the 
whey, and must be destroyed before the whey can be mixed either 
with milk or cream for the purpose of modification. In order to 
do this the whey must be heated to the temperature of 165° F., at 
least — that is, Pasteurized — for thirty minutes. Older authors advo- 
cated bringing the whey to a boil. Whey, as such, without the 
addition of cream or milk, is exceedingly useful in feeding infants 
who are suffering from enteric catarrh. It contains, as is seen, the 
liquid proteid substances of the milk, with salts and water. An 
infant can be kept on such a diet for several days without the 
danger of being starved. It has certain advantages over albumin- 
water, which will be described later. It is acid in reaction, and 
may be sweetened with sugar if the children object to taking it. 

The principle of its introduction into infant-feeding, combined 
with certain percentages of cream, is founded on the fact that, when 
we modify cream or milk to make it conform to the formula as 
found in human milk, we are still dealing with a casein which is 
not present in proportion to the lactalbumin as it is in human milk. 
By thus separating the liquid proteids from the casein and recom- 
bining them this disparity of percentage is overcome. 

The proportion, as has been stated before, of the casein or case- 
inogen to the remaining proteids of cows' milk — the lactalbumin 
and lactoglobulin — is five-sixths of casein to one-sixth of lactalbu- 
min and lactoglobulin, as compared to human milk, which contains 
two sixths of caseinogen and four-sixths of lactalbumin and lacto- 
globulin. In the whey we obtain all the absorbable proteids ; and 
if we use cream, which is highly concentrated, for fat-proportions 
and skim milk to obtain the caseinogen, we can make a mixture 
which both relatively and actually contains the same proportions of 
caseinogen, lactalbumin, and lactoglobulin as human milk. It must be 
said at the start, however, that the preparation of milk modified 
by the whey method is carried out with the greatest difficulty at 
home ; and even when constructed at the laboratory the method has 
not yet been perfected to such an extent as to be entirely devoid of 
objection. It very frequently happens that unless the whey is thor- 
oughly and most carefully Pasteurized, the modified milk curdles 
when heated. It is very difficult thus to prepare the whey mixture. 
It has not come into vogue for the reason that the physicians have not 
yet accustomed themselves to the theory of preparing these solutions. 



SHALL TEE PHYSICIAN BE SORT TO INFANT FOODS? 157 

It is also found that the manipulation to which the milk is subjected 
is open to the same objections that ordinarily obtain with modified 
milk as prepared at the laboratory. Children, for some reason not 
yet explained, do not thrive as well on these carefully prepared 
mixtures as they do on mixtures prepared in the ordinary way. 
White and Ladd have reduced casein in these mixtures so that, 
with concentrated cream, skim milk, and whey, they obtain mixtures 
in which caseinogen and casein, as stated, bear the same proportions 
relatively to the lactalbumin and lactoglobulin as it does in the 
human milk; that is, with a total proteid percentage of 1.25, two- 
thirds are whey proteids and one-third caseinogen. 

The following table shows a few of the combinations of caseinogen 
and lactalbumin obtainable from the laboratory : 

Fat. Caseinogen. Lactalbumin. Sugar. 

1.00 per cent. 0.25 per cent. 0.25 per cent. 4 to 7 per cent. 

1.50 " 0.25 " 0.75 " 4 to 7 

2.00 " 0.50 " 0.75 " 4 to 7 

2.50 " 0.50 " 0.75 " 4 to 7 

3.00 or 3.50 " 0.50 " 0.75 " 4 to 7 



SHALL THE PHYSICIAN RESORT TO INFANT FOODS? 

Under the heading of Infant Foods have been indicated the con- 
ditions under which these foods may be utilized. No conditions 
there laid down presuppose that any infant food may be used as an 
exclusive diet for the infant. Infant foods are only either a tem- 
porary makeshift — where milk for some reason must be excluded 
from the dietary — or they may be added to milk to aid its assimila- 
tion. In the first set belong the infant foods which have been indi- 
cated under the heading devoted to this subject, such as Imperial 
Granum or the carefully prepared cereals. These foods are used in 
forms of dyspepsia or intestinal disease to tide over a critical period. 
To the second class belong the infant foods of the malted varieties, 
such as Mellin's Food, which are added to the milk to aid its assimi- 
lation. In other words, we utilize the diastase or malted sugar to 
aid in the digestion of the proteids of the milk. 

Barley-gruels and How to Utilize Them. — Some physicians ob- 
ject to the addition of barley-gruel in any strength to the milk 
intended for the normal infant, on the ground that the gut of the 
infant is not prepared for the assimilation of starchy food, and we 
find authorities who deprecate the use of barley-gruel for the new- 
born infant, on the ground that it is difficult o( digestion. We 
find others who deprecate the use o( barley-gruel under all conditions 
oilier than actual disease. The author's experience does no1 carry out 



158 NUTRITION AND INFANT FEEDING. 

the assertion that barley-gruel is not well borne by the newborn infant. 
On the contrary, some of the most successful cases of infant-feeding 
are those of newborn infants whose percentage mixture contained 
as a basis a thin barley-gruel. These cases are especially those new- 
born infants with whom the digestion of the fats is very difficult. 
The barley-gruel for these infants is as follows: A heaping tea- 
spoonful of Robinson's Patent Barley is allowed to a pint of water. 
This is dissolved, then stirred over a gas-name, brought to a boil, and 
kept at this temperature for fully ten minutes. While the barley- 
gruel is boiling, the amount of milk-sugar requisite for the infant's 
mixture is added. The gruel is then allowed to cool, and the top 
cream is added in the requisite percentage quantity. If prepared in 
this way we will have greater success than with a barley-gruel only 
momentarily heated to the boiling-point. 

Milk mixtures prepared in this way have a consistence of thin 
gruel and are quite well borne, not only by the newborn infant, but 
throughout the nursing period. The use of so-called dextrinized 
barley in the making of the gruel, on the other hand, is not well borne 
by younger infants, inasmuch as there is a greater residue and the 
solution is not as complete as with the ordinary Robinson's Patent 
Barley. 

Dextrinized barley is rather indicated from the third month .to 
the later periods of infancy, and even when this gruel is not as well 
borne by some infants as the ordinary barley-gruel above indicated. 
There is no question in my mind that the addition of a barley-gruel 
to a milk mixture aids in the assimilation of the curd of the milk. 
This can be well seen when an infant taking such a mixture spits up 
a small quantity after feeding. The curd thus rejected is very finely 
divided, and closely resembles the curd of mother's milk. 

Dextrinized Gruels as Infant Food.— Jacobi was the first in this 
country to advocate the addition of a cereal decoction to milk in di- 
lutions to aid the digestion of the casein in the cows' milk. From this 
has developed the addition of dextrinized gruels to cows' milk, with 
the same end in view. Chapin, in this country, and Keller, in 
Germany, advocate this method of infant-feeding. 

So far as the Chapin method is concerned, it consists principally 
in dextrinizing a thin gruel of barley or flour by means of a diastase 
preparation (Cereo), adding this to the milk, and administering it in 
this fashion to the infant. Chapin advocates the administration of 
dextrinized gruels in combination with milk in percentage dilutions 
both for healthy and sick infants. The author cannot see the necessity 
for dextrinizing any dilution of milk for the normal infant. 

Keller has advocated the use of these gruels with sick infants, 



SHALL THE PHYSICIAN RESORT TO INFANT FOODS? 159 

especially of the marantic type, and in this respect the author's 
experience carries out the contention of Keller, that much can be 
accomplished by the use of these dextrinized gruels. The majority 
of pediatrists use no other diluent than water for the milk of normal 
infants. In the present method some form of diastase, either pure or 
combined with malt extract, is added to the cereal dilution. Chapin 
takes a tablespoonful of flour, adds this to 1-J pints of water, and boils 
the mixture for fifteen minutes. He then adds a teaspoonful of a 
solution of diastase (so-called Cereo) to the mixture, the gruel be- 
comes thin, and is then considered dextrinized. In this form it is 
added to the milk as a diluent in the requisite quantity. 

Keller utilizes the formula of Liebig in making a malt extract. 
To this malt extract potassium carbonate is added as an animal salt. 
One hundred grammes of this malt extract are added to 500 c.c. of 
water, or 1 pint, and dissolved. This is solution No. 1. He then 
suspends 50 grammes of wheat flour in 500 c.c. of milk, so that the 
solution is quite uniform. He then strains the milk and flour through 
cheesecloth. The solution of malt extract and that of the milk and 
flour are mixed together, put into a common vessel, and stirred con- 
stantly over a slow fire. After about twenty minutes of stirring the 
whole mixture is brought to a boil to stop all processes of digestion. 
The mixture is now put up in bottles, each containing about 6 ounces, 
corked, and kept cool. This mixture contains dextrinized cereal and 
malt-sugar in addition to the milk. The Liebig malt extract utilized 
by Keller is composed of maltose, 57 per cent. ; dextrine, 12.4 per 
cent. Wheat contains 66.8 per cent, of starch, 7.5 per cent, of 
dextrine, and a small amount of dextrose. By the action of the 
ferments in the malt extracts — principally diastase — the starches are 
converted into sugars. By this method a number of easily assim- 
ilable substances are introduced into the economy. The action of 
these processes on the casein coagulation seems favorable to its 
assimilation. 

The acid intoxication of intestinal origin said to be present in 
these infants, is neutralized. Ammonia, which is an index of dis- 
turbed intestinal metabolism, diminishes and finally disappears from 
the urine. It should be borne in mind, however, that in feeding in- 
fants of the marantic type on dextrinized gruel or any over-cooked 
food, there is great danger of the development of scurvy. We cannot 
therefore feed these infants for any length of time on these foods, 
for not only do they develop scorbutic symptoms, but after a while 
cease to increase in weight, or remain stationary, become anemic, and 
are then in as bad a condition as they were at first. 



160 NUTRITION AND INFANT FEEDING. 

FOOD OF BREAST-FED OR BOTTLE-FED INFANTS AFTER THE 

SIXTH MONTH. 

It has been shown by Camerer and Eotch that the secretion of 
breast milk reaches its highest limits, both in quality and quantity, 
during the first six months of lactation. In many cases the quantity 
of milk diminishes, as also its quality. If the infant gains steadily in 
weight after the sixth month, no additional food is indicated. If, 
however, the increase of weight is not satisfactory, we may at this 
period begin with the daily administration of one or two bottles of 
modified cows' milk, in addition to the breast, continued until the 
infant is completely weaned. On the eruption of the incisor teeth, at 
the seventh month, the infant is allowed a cereal, in the shape of pre- 
pared barley, as a pap, with cracker or rusk of bread once or twice 
a day. If the infant is inclined to be constipated, the barley is 
omitted. The same procedure is followed as to cereals with bottle- 
fed infants after the seventh or eighth month. 

FEEDING FROM THE NINTH TO THE TWELFTH MONTH. 

Breast-fed Infants. — Weaning. — It is not advisable to attempt 
weaning at the outset of the summer, even though we may be com- 
pelled to keep the infant at the breast a few months longer than 
usual. If the infant is partially weaned — that is, on a mixed feed- 
ing of breast and bottle — it should not be deprived of the breast 
entirely during the summer season. The reason for this is quite 
evident. During the summer a bottle-fed infant is very likely to be 
upset should anything happen to the milk. We would therefore be 
compelled to suspend the feeding with the bottle, proceed without 
milk for a few days, and then gradually return to the milk diet. 
In doing this our task will be less difficult if we have even a scantily 
secreted breast milk at our disposal. Convalescence from a dys- 
peptic attack will be much more rapid if return is made cautiously 
to breast milk than to a substitute feeding. 

It takes about eight weeks to wean an infant completely. Sudden 
weaning of an infant from the breast is not only inadvisable, but in 
some cases attended with the greatest difficulties. If the infant has 
had the benefit of one or two additional bottles daily from the sixth 
month, the task of weaning is comparatively simple. If, however, 
the infant has been kept on the breast exclusively until the ninth 
month, when weaning is attempted certain difficulties will at once 
appear. The infant will not take the bottle if there is a breast at 
its disposal. The only way out of the difficulty is to deprive the 
infant at certain times of the day of the breast, and thus starve it 
into taking the bottle. This requires moral courage on the part of 
the mother and of the physician. 



FEEDING FEOM TWELFTH TO EIGHTEENTH MONTH. 161 

In those cases in which the mother nurses the infant we cannot 
always gain her cooperation in denying the breast to the infant. The 
difficulties of weaning in such cases are only increased, but with 
patience we can ultimately overcome them. I have seen infants who 
were deprived of the breast at this period refuse to take but a few 
ounces of nourishment daily for weeks. They emaciate, become 
restless, and refuse to be pacified. Under certain conditions, where 
the nursing function has been discontinued and the milk secretion 
has therefore ceased, the situation is at times really critical. But I 
have invariably seen the child take to his artificial food in due season, 
even if this surrender was delayed for a long period of time. Patience 
will ultimately conquer the little one in these cases. 

In weaning I give those modifications of cows' milk which con- 
tain from 1 to 1.5 per cent, of proteids and 2 to 2.5 per cent, of fats 
until the infant is fully weaned. I then increase the strength of the 
milk to that given to the bottle-fed infant at the ninth month. At 
this time the bottle-fed infant is given almost whole milk. It is 
always well to mix wth the milk a small quantity of water, in the 
proportion of 1 ounce of water to 7 of milk. Some infants who 
have been at the breast up to the ninth month will apparently refuse 
to take any modifications of milk which contain the cereal decoc- 
tions. In these cases I have tempted the infants with small quanti- 
ties of raw milk slightly diluted with water, foregoing all attempts 
at percentage modification. This seems to have succeeeled the best 
in trying cases. 

In addition, the author gives from the ninth to the twelfth month, 
both to breast- and bottle-fed infants, cereals, in the shape of pap 
made up with barley, granum, rusk, and crackers, twice daily. For 
some of these infants an ounce of expressed beef -juice is mixed with 
equal portions of barley-water and slightly salted. This is given 
once a day. Infants relish this change. 

FEEDING- FROM THE TWELFTH TO THE EIGHTEENTH MONTH. 

At this period it is desirable to place the child on a diet containing 
milk, cereals, eggs, and beef-juice, in the following manner: Four to 
five meals are given daily. At each, milk forms the basis of nourish- 
ment, generally accompanied by rusk or crackers. An egg is given 
once a day, beginning with the half and increasing to the whole egg as 
the infant grows older. At this time, also, fruit-juices, such as 
orange-jnice or prune-juice, may be given, especially to those who 
exhibit a rachitic tendency ov who are constipated. The juice of half 
an orange daily will be relished by most children. 

The dietary is divided into four or five meals daily. If infants 

li 



162 NUTRITION AND INFANT FEEDING. 

are markedly rachitic the author allows, in addition to the dietary 
below, a small amount of chicken meat, as much as will adhere to the 
bone of a chicken. This is given to the child once a day. 

Milk. — A quart and a half a pint to a pint daily. 

Cereals. — Rusk or crackers, two of each a day; sponge cake in 
the form of long sugared slices ; barley, granum, or oatmeal (the 
latter strained) in the form of a pap once a day. 

Eggs. — One soft-boiled or coddled egg a day. 

Meat. — Beef -juice expressed, mixed with equal portions of barley- 
water and slightly salted to the taste, about 2 to 4 ounces daily. 

FEEDING FROM THE EIGHTEENTH MONTH TO THE END OF THE 

SECOND YEAR. 

At this time the child is placed on a mixed carbohydrate and 
nitrogenous diet, consisting for the most part of milk, which is the 
basis of the diet; eggs; soup or beef -juice; meat of the beef or 
chicken ; vegetables ; cereals. These are divided into four meals daily : 

Milk. — Some children will take considerable, some very little, 
milk at this period. 

Eggs. — The eggs are boiled soft or coddled. Some children will 
take at least one egg a day, others two ; some will not take egg at all. 

Soups. — Parents are apt to overstep the mark in giving large 
quantities of soup — in fact, an adult portion — to children. This is 
scarcely desirable, inasmuch as it displaces other food, such as milk, 
and contains large quantities of salts and insoluble products, such 
as keratin. The amount should not exceed 4 ounces. 

Meats. — The ordinary boiled meat is by far the best for children. 
The inside of a lamb chop, a small piece of well-done beefsteak, 
roast beef, and chicken. Gamey meats, and fat meat, such as mutton, 
ham, pork, should be avoided. 

Vegetables. — These include potatoes, peas, beans, carrots, spinach, 
the green vegetables being especially desirable, inasmuch as they 
contain iron. x\ll vegetables should be given in a mashed form. 

Cereals. — These should include barley, rice, granum, wheatena, 
oatmeal, rusk, crackers of all kinds, cocoa, and farina. 

Fruits. — Orange-juice, ripe apples, and pears, prunes or prune- 
juice. 

The articles of diet which should be avoided are vinegar, cabbage, 
salad, coffee, tea, wine, soups that contain too great an amount of 
amylacea. 

A dietary consisting of the above foods might be formulated as 
follows : 

Up to the end of the third year : 



FEEDING TO THE SIXTH YEAR AND AFTEE. 1 63 

Breakfast, 8 a. m. : juice of one orange ; 10 ounces of milk, with or 
without a cereal. A slice of bread or crackers and an egg. 

Dinner, 1 p. m. : 120 grammes (4 ounces) of soup ; 75 grammes 
(2.5 ounces) of meat with vegetables, and a fruit dessert; some milk. 

Afternoon Lunch, 4 p. m. : 250 c.c. (8 ounces) of milk or cocoa 
with rusk or crackers. 

Supper, 6 : 30 to 7 p. m. : Soft egg, 250 c.c. (8 ounces) of milk ; 
cracker, toasted bread, or farina in the milk. 

Candy. — I allow one or two pieces of candy daily, generally good 
chocolate, to older children. 

FEEDING THE THIRD TO THE SIXTH YEAR AND AFTER. 

From the third to the sixth year of life the diet should be mostly 
fluid or semifluid. The basis of all such diets should be milk. 
Milk soups, eggs, meat, butter, cocoa, bread, fresh vegetables, and 
fruits. The number of meals a day should be three or four. 

The following is a schedule of a liberal diet at this time : 

Breakfast, 8 a. m. : orange-juice, 330 c.c. (11 ounces) of milk, 
with or without cereal, egg, buttered bread, or toast, about half an 
ounce of sweet butter being allowed. 

Dinner, 1 p. m. : 180 c.c. (6 ounces) of soup; meat, 90 grammes 
(3 ounces), vegetables, a dessert, generally of baked apples. 

Afternoon Lunch, 4 p. m. : 240 c.c. (8 ounces) of milk, rusk or 
a slice of bread, or cracker. 

Supper, 7 p. m. : 240 c.c. (8 ounces) of milk mixed with some 
cereal, generally farina, 1 soft egg. 

This is a liberal diet. Some children will take as much as is here 
prescribed, others will take less. Some children are particularly 
fond of fish, and this may be given once or twice a week, generally 
in the boiled form with an egg sauce. Fried fish should not be 
allowed. It is advisable, especially in exceedingly nervous children 
or in those who have a lithic tendency, to substitute meat once or 
twice weekly by fish. 

The above form of diet with slight modifications is suitable up to 
the tenth year of life. The object of all dietaries after the eighteenth 
month is to mix the carbohydrates, fat, and albuminoids in rational 
proportions. The following table by Camerer distinctly demonstrates 
this : 



{Second to 
fourth year. 
12.7 kilos. 



Five to Seven to 

Age and weight . . \ fourth year. six years. ten years. 

18.7 kilos. 24 kilos. 

Total food (daily) . . 1183 grammes. 1517 grammes. 1699 grammes. 

Albumin 40 " 64 " 67 

Fat 39 " 46 « 32 

Carbohydrates ... 117 " \\K " 251 

Water 957 " 1200 M 1833 



1 64 NUTRITION AND INFANT FEEDING. 

THE FEEDING OF SICK INFANTS AND CHILDREN. 

The feeding of sick infants is considered under the headings of 
the various diseases. It must be borne in mind that infants and 
children, if left to their own resources, would take either very little 
nourishment or too much. In certain marantic conditions infants will 
take very large quantities of food if it is given to them. The infant's 
cries are interpreted by the mother as being due to hunger, when 
they may be due to colic or intestinal distention. In these cases the 
mother gives too great a quantity of food, and the infants suffer from 
distention of the stomach or intestine. In typhoid fever, pneumonia, 
or other acute disease the patient, if fed at long intervals, takes but 
little food. Such patients should take small quantities at short 
intervals. If the infant takes a small quantity at each feeding, the 
aggregate amount in twenty-four hours is sufficient to maintain 
nutrition. 

After operations, such as those for empyema, infants and children 
must be carefully and systematically fed in order that they may 
combat the ravages of disease. The necessity of careful feeding is 
seen in typhoid fever in the fifth and sixth weeks, at which time 
there is great emaciation and the temperature has dropped to the 
normal. If we fail to feed these patients, . they remain emaciated 
and show slight inanition temperatures. On the other hand, we must 
not give large quantities of indigestible food. We must choose the 
foods carefully. Convalescents can take much larger quantities of 
food in twenty-four hours than the normal, healthy child. The 
quantity given at each feeding should be smaller than in health. 
The nitrogenous foods, such as milk and eggs, and also sugars, 
starches, and cereals of all kinds, are easily assimilable. Alcoholics, 
when given, should be well diluted. Rectal feeding is contraindicated 
in diarrhceal conditions and states of rectal intolerance. On the 
other hand, if the stomach rejects food repeatedly, it is well to give 
that organ complete rest. Under such conditions even water is not 
introduced into the stomach. The patient is fed for twenty-four 
hours or more bv rectum. 



SECTION III 

DISEASES OF THE NEWBORN. 

PHYSIOLOGY OF THE NEWBORN. 

Respiration. — Inasmuch as cardiac action and muscular move- 
ment occur during the intra-uterine life of the foetus, the first im- 
portant function performed by the newborn infant is that of respira- 
tion. The cause of the first inspiratory act of the newborn has been a 
matter of much discussion; whereas some contend that mechanical 
stimulus brought into play by the act of parturition is the primary 
cause of the first inspiratory act of the infant, others have insisted 
that the change of temperature from the uterus to that of the ex- 
ternal world, acting on the surface of the body, is sufficient stimu- 
lus to cause, by reflex action, the first act of inspiration. Both 
these theories have been disproved, especially by the work of Ahl- 
feld. The consensus of opinion is, that the first inspiration of 
the newborn is a direct result of the separation of the placenta 
with the cessation of the normal foetal aeration of the blood ; as a 
result of this there are diminution of oxygen in the foetal blood, 
increase in carbonic-acid gas, and marked stimulation of the res- 
piratory centre of the newborn in the medulla. This theory is borne 
out by the fact that in premature separation of the placenta this 
stimulus to the performance of inspiration on the part of the foetus 
occurs before birth in the uterus or in any part of the parturient 
canal. There are rare cases also in which the foetus is born before 
separation of the placenta from the walls of the uterus. In such 
instances the birth has been very rapid and the resistance to the 
passage of the foetus slight; as a result of the uterus having con- 
tracted but little, the placenta remains in situ for a short space of 
time after birth of the foetus. Such a case has been published by 
Kehrer, and in this case the foetus was born in a state of uterine 
apnoea, the color of the skin being pink, the infant not breathing, 
but at most performing the intra-uterine respiratory movements of the 
trunk, as described by Aid fold. Such cases would seem to prove the 
truth of the theory thai if the placenta still remains attached to 
the uterine walls, and the interchange of oxygen between the maternal 
and foetal blood continues, the stimulus to the medullary centres 
mentioned above is lacking. 'There is thus no inspiration in such 
cases until the placenta separates. AUfeld 1ms shown thai in uiero 

t (>:> 



166 DISEASES OF TEE NEWBOBN. 

the foetus performs certain rhythmic movements of the trunk and 
extremities, which he interprets as respiratory in their nature. 
There are thus, according to these experiments, respiratory move- 
ments performed by the foetus in utero. These, however, are of the 
most superficial character, and do not lead to aspiration of liquor 
amnii either by mouth or nostrils. It is the intensification of these 
intra-uterine respiratory movements which eventuates in the first act 
of respiration of the newborn. Though the existence of intra-uterine 
foetal respiratory waves as conducted by the liquor amnii to the 
uterine wall have been verified by a number of observers, their in- 
terpretation is diverse and their significance is still a matter of dis- 
cussion. 

The Rhythm. — The rhythm of respiration in the newborn is quite 
irregular. Deep insjDiration and expiration are followed by regular 
respiration, with an apparent pause in which the respiratory move- 
ments are so superficial that the infant scarcely seems to breathe, and 
in which the respiratory movements can only be detected by the 
chymograph, this in a manner recalling the intra-uterine respiration 
of Ahlfeld. During sleep the respiration is more regular, but is 
influenced by the least external source of disturbance, such as a 
change in the surrounding light, air, and covering of the newborn. 

The frequency of respiration can thus be of varying rapidity. 
Dohrn found that, regardless of sleep or waking, the number of res- 
pirations of the newborn was on the average 62 ; during the act of 
crying 47. 

The type of respiration in the newborn, either in the male or 
female, is predominantly thoracic. 

The Aeration. — The aeration of the lungs — that is, the replace- 
ment of inspired by expired air — is much more thorough in the lungs 
of the newborn than later in life. In other words, if, as has been 
proved by Dohrn, 38 c.c. of air are inspired on the first day of life, 
this is renewed by each inspiration and expiration to such an extent 
that there is little residual air in the lung. In the adult lung the 
contrary obtains, there being, even on forced expiration, enough air 
left in the lung and retained there to be demonstrated by collapse of 
the organ when the thorax is opened and atmospheric pressure is 
allowed to act on the viscus. In the newborn, if the thorax is opened 
post-mortem, no such collapse of the lung takes place, but enough air 
remains in the organ to enable it to float if placed in water — that is, 
a minimum amount of air. The lung of the newborn unfolds gradu- 
ally, so that in an infant two weeks old there are patches of the 
lung which have still not been aerated, although the infant has 
breathed normally all this time. That the lung does unfold gradu- 
ally is proved by the fact that, while immediately postpartum, 38 c.c. 



1 



PHYSIOLOGY OF TEE NEWBORN. 167 

of air are taken into the lungs with each inspiration, this, on the 
tenth day of life, has increased to a volume of 50 c.c. 

Circulation, — At the moment of birth of the infant certain changes 
take place in the circulatory system which mark the transition from 
intra-uterine as distinguished from extra-uterine life. These changes 
occur in the foramen ovale, the ductus Botalli, and the umbilical ar- 
teries and veins. On the first inspiration the lungs expand and the 
blood passes into the organ. The pressure is immediately lowered in 
the right auricle on account of the diminished resistance of the pulmo- 
nary capillaries; the pressure in the left auricle is correspondingly 
increased. The foramen ovale, situated in the auricular septum, 
with a valvular slit-like opening toward the left auricle, is naturally 
closed by the increased pressure in the left auricle, and from thence 
forward there is no interchange of blood between the right and left 
auricle as in foetal life. 

The closure of the ductus Botalli is a matter of much discussion. 
The explanation of its closure given by Strassmann is now accepted 
by most observers. On expansion of the lungs and the establish- 
ment of the smaller pulmonary circulation, the pressure in the pul- 
monary artery is diminished and that in the aorta increased. The 
ductus Botalli, passing as it does from before backward from the 
pulmonary artery to the aorta, enters the latter vessel at an acute 
angle. Its lumen at the aortic extremity is funnel-like and closed 
by a slit-like valvular arrangement, whereas during foetal life, the 
pressure being greater in the pulmonary artery than in the aorta, it 
was possible for blood to pass through the ductus Botalli into the 
aorta. At birth, the pressure conditions being reversed, it becomes 
impossible for blood to pass from the pulmonary artery to the aorta, 
the pressure in the pulmonary artery not being equal to driving the 
blood through the ductus against the increased postnatal pressure 
in the aorta. The ductus thus becomes emptied, and its function as 
a circulatory organ connecting the pulmonary artery and the aorta 
ceases. ~No clot is formed except in rare cases in the lumen of the 
ductus. In utero, from the fifth month on, there is a gradual dimi- 
nution in the calibre of the vessel ; within two or three days after 
birth the calibre is so narrowed that a probe cannot be insinuated 
within it. The aortic extremity in many cases is never entirely oc- 
cluded, although most of the vessels became subsequently obliterated. 

At birth the umbilical arteries arc closed by a process similar to 
that which is described above. The firsl inspiration with conse- 
quent inflation of the lung and the establishmenl of the pulmonary 
circulation causes a fall of arterial pressure in the descending aorta. 
The blood ceases to flow through the umbilical arteries. The mus- 
cular coats of these vessels, being particularly well developed, tend 



168 DISEASES OF THE XEWBOKN. 

to contract, and enclose in their lumen an extended fibrinous clot. 
When the cord is tied this clot extends from the umbilicus to the 
hypogastric arteries. It is the adherence of the thrombi to the walls 
of these vessels and their subsequent organization which causes the 
obliteration of the lumen of the umbilical arteries, although this is 
not complete except at the situation of the umbilicus. 

The umbilical veins are obliterated in a physiological manner by 
the pressure of the uterus on the placenta. This forces the reserve 
blood in the placenta into the body of the foetus, the act of inspiration 
favoring the flow of blood from the placenta to the body of the foetus. 
Budin has shown that if the umbilical cord is divided too soon after 
birth blood to the amount of about 100 c.c. flows from the veins. If 
ligation of the cord is delayed, however, this quantity of blood is 
aspirated, so to speak, by the infant into its body from the placental 
sinuses. 

After ligation of the cord, therefore, the natural physiological 
condition of the circulation favors the collapse and obliteration of the 
umbilical veins. 

Pulse. — The pulse of the newborn infant is irregular in frequency 
and shows certain constant characteristics. Immediately after birth 
the frequency reaches 150 to 190 beats a minute. This rapidity is 
due probably to the new conditions inaugurated at birth in the cir- 
culation and the increased amount of work caused by respiration and 
pulmonary circulation, thrown upon the left ventricle. After a short 
lapse of time, from twenty minutes to an hour after birth, the pulse 
frequency sinks to less than 100 during sleep. During waking, 
nursing, crying, muscular exercise, there is a slight increase in fre- 
quency. After three to Sxe days the pulse mounts in frequency from 
120 to 135 beats per minute, but never again attains the rapidity 
observed immediately after birth. The rise in frequency of the 
pulse after its primary fall may be due not only to the recovery of 
the circulatory system, especially the heart, from the effects of rapid 
changes of tension in its various parts, incident to the new extra- 
uterine conditions, but to the beginning influence of the vagus on 
the left ventricle. 

The influence of sex on the frequency of the pulse is evident in 
the newborn as in later life, the pulse of girls during sleep being 
two or three beats more frequent to the minute than that of boys. 
During exercise the pulse of the male newborn infant is more fre- 
quent than that of the female. The true cause of these differences 
is as yet obscure. 

Blood. — The amount of blood of the newborn as compared with 
the body-weight varies with the time of ligation of the umbilical cord. 
If the cord is ligated at once the quantity of blood is one-fourteenth 



PHYSIOLOGY OF TEE NEWBOBN. 169 

to one-sixteenth of that of the body-weight ; whereas in cases of late. 
ligation of the cord it is one-tenth to one-eleventh of the body-weight. 

The histological characteristics of the blood of the newborn are 
so striking as to merit brief mention here. The blood contains a 
large number of nucleated, red blood-cells; the red blood-cells do not 
tend to collect in rouleux, and show very little or no central depres- 
sion, as later on. The number of red blood-cells is not only greater 
to the cubic millimetre than later in infancy, but the haemoglobin 
percentage of the blood and of the individual erythrocyte is much higher 
than later on. The red blood-cells show also the central "shadows" 
to a greater extent than is seen later in infancy. The white cells are 
present in larger numbers relative to the red blood-cells than later in 
infancy, and this proportion is still greater after feeding. 

The white blood-cells have a marked tendency also to group them- 
selves in clumps. These characteristics of the blood gradually dis- 
appear toward the eleventh day, and are most pronounced on the 
fourth day after birth. It can thus be seen that the blood picture 
obtained during the first days of life is such as would be of grave 
pathological import if found in the adult. 

Digestive Functions. — The saliva is secreted in much less quan- 
tity in the newborn than later in infancy, and is present in just suffi- 
cient amount to moisten the mucous membrane of the mouth. Its 
reaction is slightly alkaline, but in disturbed conditions of the mucous 
membrane of the mouth it becomes acid. The amylolytic ferments 
are present only in the secretion of the parotid gland, and here only 
to a slight degree. The secretion of the submaxillary gland shows 
this property only after the third month of infancy (Zweifel). 

Pepsin is found in the stomach of the embryo at the fourth month, 
whereas hydrochloric acid is found in this organ only during the later 
months of foetal life. Both are present in the stomach of the new- 
born infant. 

The pancreatic secretion in the newborn, while incapable of con- 
verting starch into sugar, does contain trypsin and a fat-splitting 
ferment. 

The properties of the secretions of the mucous membrane of the 
intestine of the newborn are still a matter of speculation. The gall- 
bladder of the newborn infant contains 0.1 to 0.3 grammes of bile, 
which is increased in amount after the ingestion of food. The bile 
contains less water and is richer in mucin, coloring-matter, and 
taurocholic acid in the newborn infant (ban at any oilier time o\' life. 
Glycocholic acid is not found in the bile o( the newborn. The physio- 
logical function of the bile is still undetermined. 

From the above it will be seen that in the newborn infant the 
digestion of starchy substances is hut feeble, whereas the* digestion of 
fats and albuminoids is as complete as in later infancy. 



170 DISEASES OF THE NEWBOEN. 

Body -temperature. — The rectal temperature of the iufaut takeu 
immediately after birth is about 0.6° C. higher thau that of the 
mother. The average temperature of the uewboru subsequent to 
depressions incident to the immediate postnatal period is 37.7° C. 
(99.6° F.). Febrile states of the mother at the time of parturition, 
or external influences, may cause a rise or fall of the body-tempera- 
ture in the newborn. Thus, a case is recorded in which an infant 
born of a mother suffering from fever at the time of labor had a 
temperature of 41° C. (105.8° F.) immediately after delivery 
(Lange, Fehling). Premature or congenitally weak infants have a 
lower rectal temperature than vigorous full-term infants. An hour 
or two after birth the body-temperature falls, but after nine to seven- 
teen hours attains 37° C. (98.6° F.). This fall may be as much as 
1.7° to 2.5° C, and is due to the cooling influence of the first bath, 
the change from the warmth of the uterine cavity to the external air, 
and the respiration. Toward the end of the first week the body- 
temperature of the newborn rises slowly to the permanent normal by 
tenths of a degree. In the congenitally weak the temperature rises 
more slowly and reaches 37° C. after twenty-four hours; whereas in 
strong and well-developed infants it reaches this limit in one-quarter 
to one-half this time. 

The temperature of the newborn is more easily depressed and 
raised by external influences than that of the adult. Thus, clothes 
and the surrounding atmosphere exert a marked influence in this 
respect. There is also a direct relation between the amount of nour- 
ishment ingested and the body-temperature. ' If the nutriment is 
insufficient, the normal temperature is attained much more slowly 
than under contrary conditions. An illustration of the influence of 
external conditions on the temperature is the case of a congenitally 
weak infant recently brought to my notice, whose temperature was 
raised fully 0.6° C. (1.5° F.) above the normal by placing warm- 
water bottles too near the body. The temperature of the newborn, 
therefore is subject to wide variations ; but it may be said that after 
the second day a temperature below 36° C. (96.8° F.) or above 38° 
C. (100.4° F.) is abnormal. The diurnal fluctuation of the body- 
temperature of the newborn is characteristic in that the highest point 
in the curve is reached in the early morning (6 a. m.) rather than in 
the evening, as in the adult. 

Skin. — The body of the newborn infant is covered with a grayish, 
cheesy material, which consists of epithelial scales and secretions 
from the sebaceous glands, called the vernix caseosa. As is well 
known, this is washed off after birth, and leaves the skin smooth and 
of a uniform pink color. The skin of the newborn infant desqua- 
mates in small and lar^e scales. This is distinctly noticeable at the 



PHYSIOLOGY OF THE NEWBORN. 171 

sixth or seventh day, and ends in the second or third week after birth. 
Small vesicles are seen to form here and there on the skin over the 
body in some infants. 

The body at birth is covered with soft, long hair called lanugo. 
This is also found on the scalp. In the first few weeks after birth 
this hair falls out and is replaced by the permanent hair. In weak- 
lings this replacement, as also desquamation of the skin, takes place 
more slowly than in stronger infants. In the first few weeks the 
sebaceous glands are especially active, and their activity is indicated 
by the appearance of the so-called scurf on the scalp. On the body, 
in the groin, on the nose and face, small white bodies are noticed in 
the newborn infant, called milia, Epstein showed that these were 
really retention cysts of sebaceous follicles of the skin. They dis- 
appear in the course of two or three weeks. 

Jaundice. — The skin, though pink in color at birth, becomes jaun- 
diced from the second to the fourth day after birth in 80 per cent, 
of newborn infants. 

Perspiration. — Although infants are hardly seen to perspire pro- 
fusely unless warmly clothed, the insensible perspiration from the 
skin and lungs is proportionately greater for the expanse of the body 
surface than in the adult. Rubner and Heubner showed that the 
infant yielded 

During the first week fully 90 grammes (3 ounces) ; 

" " second and third months 192 grammes (6£ ounces) ; 

" " fifth and sixth " 290 grammes (9f ounces) ; 

" " first year 460 grammes (15£ ounces) 

of insensible perspiration daily, as compared with 650 grammes (21f 
ounces of the adult. 

Breasts. — From the third to the fifth day after birth milk appears 
in the breasts of the newborn infant of both sexes. As a rule, the 
secretion appears earlier in the breasts of girls than in boys. The 
breasts become swollen and tense ; one gland, generally the right, 
functionating sooner than the other. The cause of this curious 
phenomenon is as yet unknown. Balantyne suggests that it is due 
to a bio-chemical relation between the foetus and the mother, which 
exercises its influence on the infant after birth in such a way thai 
the same agencies which cause 1 a production of milk in the mother 
continue to produce the same result in the infant. The secretion has 
been examined by Barfurth, llerx, ami others, and has been found to 
be composed of proteids, 2.5 to 2.6 pel emit.: fat, 2.3 to 3 per cent.; 
sugar, 2.5 per cent. It is therefore a real secretion o( milk, and the 
method of its secretion is the same as in the adult gland. The 
amount of milk which is called DY the laitv " witches' milk." is small. 



172 



DISEASES OF THE NEWBORN. 



The secretion lasts, as a rule, from six to eight weeks ; in exceptional 
cases it may continue six months (Herz). If mastitis occur, it is 
certainly the result either of antepartum or postpartum infection, and 



not of caking of the breasts. 



Fro. 20. 




Caking of the milk in both breasts of a newborn infant. 



Urine. — Speaking of the urine of the newborn in a stricter sense, 
the amount passed spontaneously after birth is on the average 9.6 
c.c, of which 7.5 c.c. may be found in the bladder at the time of 
birth, unless the viscus has been subjected to pressure during birth. 
The urine is passed spontaneously within twenty-four hours after 
birth in 66 per cent, of newborn infants, and in the remaining cases 
within forty-eight hours after birth. 

Quantity. — The daily quantity of urine during the first two weeks 
varies widely according to different observers. On an average the 
amount varies in breast-fed and bottle-fed infants according to the 
amount of fluid food ingested. In breast-fed infants the amount 
during the first three days increases from 17 c.c. to 43 to 49 c.c, and 



PHYSIOLOGY OF THE NEWBORN. 173 

on the fourth day' amounts to 116 c.c., due to an increase of milk in 
the mother's breast. On the fourteenth day the amount has run up 
to 263 c.c. " 

Hofmeier and Schiff have shown that infants in whom the cord 
has been tied early, and in whom the gross amount of blood in circu- 
lation is less than in those in whom the cord has been tied late, the 
daily quantity of urine will be proportionately less. As soon as a 
constant relationship is established between the amount of fluid taken 
into the body and that excreted, toward the seventh day, then the 
amount of urine excreted reaches the proportionate relationship to 
the body-weight that exists in the adult. Thus, whereas on the first 
day 21.8 to 38.8 per cent, of the milk taken is excreted in the form 
of urine (Cruse, Reusing), on the eighth day it reaches the constant 
proportion of 62.8 per cent., as in the adult. The amount of urine 
proportionate to each kilogramme of body-weight must necessarily 
increase more markedly during the first eight days, inasmuch as, 
while the body-weight during this time is more or less stationary, the 
gross amount of urine increases. Thus, the first day it amounts to 
5.9 c.c. to each kilogramme; on the eighth day it reaches 67.4 c.c, 
on the tenth day 90 c.c, and then remains stationary. These figures 
are higher than is true of the adult, in whom the daily amount of 
urine per kilogramme of body-weight is 25 c.c 

Color. — The urine of the newborn is almost colorless ; its specific 
gravity in the foetus is 1002.8 (Dohrn) ; in the first two days of life 
1008 to 1009, on the third day 1011 to 1013, and on the tenth day it 
falls to 1003 to 1004. In bottle-fed infants the specific gravity is 
lower than in the breast-fed infant, due to the increased amount of 
milk ingested. The reaction of the urine of the newborn is con- 
stantly acid in all but 3 per cent. (Hofmeier). The urine of new- 
born infants during the first five days of life contains renal epithe- 
lium, uric-acid crystals, amorphous urates, and frequently casts. 
Hyaline and granular casts were found by Reusing in 39.4 per cent, 
of breast-fed and in 9 per cent, of bottle-fed infants during the first 
days of life. If casts are present, there is also, as a rule, albumin. 

Urea. — The amount of urea increases absolutely and relatively 
from the first day of life. Thus, it increases in absolute quantity 
from 0.06 to 0.11 the first day, to 0.82 on the eleventh day, or, rela- 
tively to each kilogramme of body-weight, 0.018 to 0.29 on the 
seventh day. 

Uric Acid. — Uric acid is presenl in the urine o( the newborn in 
remarkably large amounts. Tims, on the firsl day the urine contains 
0.0136 of uric acid to each kilogramme of body-weight. That is 
much greater than in the adult. The proportion of uric arid to urea 
is much greater in the newborn than at any oilier period of life: in 



174 DISEASES OF THE NEWBOEN. 

the adult it reaches the high relative percentage of the newborn only 
in pathological states. Thus, in the adult the relative proportion of 
uric acid to urea is as 1 : 41 or 61, whereas in the newborn it ranges 
from 1:1.5 on the first day to 1 : 21.9 on the seventh day of life. 

Albumin. — Albumin is found immediately after birth in the urine 
in 38 per cent, of infants (Dohrn). Dohrn ascribes its presence as 
due to complications during birth or disturbances, however slight, 
of the circulation. Hofmeier found it disappeared toward the end 
of the first week; also that there was a constant relationship between 
the excretion of uric acid and the presence of albumin in the urine 
of the newborn, the latter being absent in those cases in which uric 
acid was not found and in which no uric acid infarction of the kidney 
existed. He attributed the albuminuria of the newborn to the me- 
chanical irritation of the deposits of uric acid on the epithelium of 
the uriniferous tubules. 

Rectal Excreta. — Meconium. — Meconium forms the gut content 
in the foetus. It is of a yellowish-green color in the small intestines 
— of a dark-green color in the large gut, becoming lighter after an 
interval of a day or so after birth. It is of a tarry consistence and 
odorless. The total quantity of meconium varies from 70 to 90 
grammes, or 24 to 3 ounces, of which 2 to 20 grammes are passed 
daily. When the infant takes the breast or cows' milk, meconium 
is mingled in the movements with the milk f feces. The first pas- 
sage of meconium occurs immediately after or in the first few hours, 
at the latest ten to twelve hours, after birth, and is preceded by the 
expulsion of the so-called meconium plug. This is a body of mucoid 
tissue 2 millimetres in diameter, and is of importance in a medico- 
legal sense. An infant stillborn will retain in the lower part of the 
rectum the meconium plug. 

The stools for the first two days consist mostly of meconium, 
which subsequently becomes mingled with the milk faeces. The move- 
ments contain both yellow and greenish residue. After the fourth 
day the infantile movements assume their permanent characteristics 
of color and consistence. The composition of meconium has been 
fully investigated. It is made up of desquamated epidermal and 
intestinal epithelium, amniotic fluid, vernix caseosa, wool-hair or 
lanugo, plates of cholesterin, scales of skin, haematoidin crystals, bili- 
rubin, fat-drops, and stearic-acid crystals. Bilirubin is peculiar to 
meconium (Zweifel and Schmidt). Weintraud found uric acid and 
alloxur bases in meconium, which were probably derived from a 
nuclein substance. Schild found that sterile meconium contained a 
peptonizing ferment; and Patevin found a lab-ferment and amylase 
in sterile meconium. 

Meconium contains also the characteristic so-called " meconium 



PHYSIOLOGY OF THE NEWBOEN. 175 

bodies." These consist of ovoid or polyhedral masses yellowish- 
green in color. They are made up of organic matter, such as masses 
of intestinal epithelium and mucus, in which are precipitated biliary 
pigments and salts. They contain biliary pigment, soluble in caustic 
potash, insoluble in ether or acetic acid. 

Chemical analysis of meconium reveals mucin, palmitin, stearin, 
olein, biliary pigments, and taurocholic acid. It does not contain 
indol or phenol, which are products of decomposition. 

During the first few days of infancy the stools contain much 
mucus of a stringy character, and the writer has frequently seen 
this actually drawn out of the rectum in shreds by the nurse in 
otherwise normal infants. 

Bacteria. — Meconium is sterile at first, and then becomes infected 
with bacteria in from three to eighteen hours after birth. A proteus 
similar to that of Hauser's is regularly found, also, a chain coccus 
and a Bacillus subtilis. With the appearance of the milk faeces, a 
bacillus similar to that of the Bacillus lactis aerogenes is found in 
the upper part of the gut, the colon bacillus in the lower portion with 
the coccobacillus of Fischl. 

Nervous System. — The nervous system is not in an active, but 
rather in a receptive, state in the newborn. 

Muscular power as well as muscular sense is but little developed. 
The newborn infant can neither sit up nor hold its head upright. 
The reflex irritability of nerve and muscle both to galvanic or faradic 
stimulus is less evident in the newborn than later in infancy or in 
the adult. Response to stimulation is distinctly delayed ; the latent 
period is more marked in the newborn. In the newborn the inhibi- 
tory functions of the vagus are not fully developed, but it is sus- 
ceptible to reflex action, as is demonstrated in cases of cerebral 
pressure with slowed pulse due to injury incident to birth. In these 
cases the vagus would seem to exert through the cerebral centres an 
inhibitory influence on the heart. The cerebrum seems to be in a 
passive rather than in an active state in the newborn. In spite of 
the divergence of views, there seems to be no sign of consciousness in 
the newborn, nor are the motor centres developed to such an extent 
as to react under stimulus. Motion is rather of a reflex nature or 
indirectly referable to the high development of the sense of touch. 
Thus, we meet with injuries of the skull-cap in the newborn which 
are of an extensive character, such as depression of the skull, giving 
no symptoms referable to the motor areas. On the other hand, there 
is sufficient reason to believe that the cerebrum exerts a negative 
inhibitory influence, and that several oi' such centres are active in the 
newborn. The skin roilex presents nothing peculiar in the newborn. 
The patellar rcllox is somewhat increased, diminishing after the 
seventh to the nineteenth day. 



176 DISEASES OF THE NEW BO EN. 

In spite of the assertions of Kussmaul and Preyer as to the 
existence of the sense of taste in the newborn, there is reason to 
believe that this sense is but little developed, and really exists in 
the nature of a reflex rather than a sense which distinguishes between 
sweet, bitter, and sour, as in the adult (Gensmer). Thus, Lange 
has given a 4 per cent, quinine solution to the newborn without 
awakening any signs as to the appreciation of its bitter taste. It 
is also questionable whether the newborn appreciates the sweet taste 
of breast milk. On the whole, it may be said that it takes a strong 
solution of any kind, sweet or bitter, to cause any visible reaction in 
the newborn, and that this reaction is rather in the nature of a gen- 
eral reflex than an appreciation of differences of sweet, sour, or bitter. 

Hearing is not evident as a sense immediately after birth, and, 
as has been pointed out elsewhere, the newborn infant is deaf. The 
sense of hearing develops at various periods after birth, from six to 
forty-eight hours, according to the rapidity with which in the new- 
born the Eustachian tube is opened up and air enters the internal ear. 
In prematurely born infants, on account of marked swelling of the 
walls of the tube, the development of the sense of hearing is much 
delayed. These facts explain the wide difference among observers 
(Kussmaul, Preyer, Gensmer) as to the development of this sense. 
Gensmer is probably correct when he says that most infants react to 
sound after the first or, at least, the second day. The improvement 
in the hearing is unmistakable in the first week. 

In the premature as well as in infants born at full term, the eye 
reflexes are developed. Thus the pupil contracts and dilates under 
stimulus, and intense light or continued flashing of light in the 
vicinity of the newborn calls forth signs of general reflex irritability; 
that is, the newborn becomes uneasy under irritation of this nature. 
It is still a matter of discussion as to whether the newborn can fix 
or focus objects and whether accommodation is developed. The 
eyelids react promptly to reflex stimulus. 

The sense of smell is but slightly developed in the newborn, and 
it is a matter of question as to whether at this time the infant may 
recognize the mother or the nipple of the breast by meaus of this 
sense. Far more probable is it that in this respect the sense of 
touch and its reflexes has been mistaken in its manifestations for 
that of smell. 

The sense of touch is the most highly developed sense in the new- 
born, and is most evident in the lips and face. The lip reflex is 
especially developed, inasmuch as in the newborn the least contact 
of any object with the lips calls forth the pursing of the lips and the 
motions attendant upon suckling. 

The appreciation of pain is absent immediately after birth, and 



PHYSIOLOGY OF THE NEWBORN. Ill 

only after one or two days does the newborn react to the irritation 
of a pin-point. 

But little is known of the appreciation of heat and cold in the 
newborn; and it may be said that these call forth only manifesta- 
tions of a general reflex action as is seen in cases of asphyxia when 
infants are brought rapidly from the warm to the cold plunge. 

Metabolism. — Though much is still to be learned as to the proc- 
esses of metabolism in the newborn, there are certain facts as to the 
daily quantity of milk taken, the amount of urine voided, the loss of 
weight by means of the skin and faeces, which have been determined 
within certain limits. 

The amount of milk consumed daily by the newborn has been 
carefully determined by weighing the infant before and after nursing. 
A well-developed infant nursing a normally secreting breast will, 
according to the investigations of Cammerer, Hahner, and Laure, 
consume the following quantities of milk, expressed in cubic centi- 
metres : 

Days 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 
33 123 209 290 305 342 400 417 426 413 441 437 516 487 536 

Excretion and Waste. — Meconium and Faeces. — As long as me- 
conium is voided the movements are small. As soon as milk faeces 
appear they average 1 to 3 grammes of fasces to 100 c.c. of milk 
ingested. An infant during the first two weeks rarely voids more 
than 10 grammes of fasces daily. The excretion of carbonic-acid gas 
and water by the skin and lungs has as yet not been accurately deter- 
mined. The experiments of Forster as to the excretion of carbonic- 
acid gas were performed on a fourteen-day-old infant. His observa- 
tions were made on the sleeping infant only, also a source of error. 
Cammerer, however, determined the daily exhalation by lungs of 
carbonic-acid gas more definitely, and found that this was as follows : 

1st day. 2d day. 3d day. End 1st week. End 2d week. 

100 grammes 85 grammes 80 grammes 100 grammes 130 to 150 grammes 

It may be said that under similar conditions the newborn infant 
exhales more carbonic-acid gas per kilogramme of body-weight than 
the adult. 

Though certain facts as to the metabolic processes are as yet unde- 
termined in the newborn, we can still form an approximate estimate 
as to the ultimate disposition of the food and the manner in which 
oxidation processes of the body are carried out in the tirst few days 
of life. Thus Cammerer has by estimating the amount of food 
ingested, and the amount of urine, faces, and carbonic-acid gas 
excreted, drawn up a very instructive tabic showing the loss ot weight 

12 



178 



DISEASES OF THE NEWBORN. 



and the manner in which it is kept within certain limits during the 
first four days of life : 



Day. 


Milk taken. 


Excreted. 


Loss of weight. 


1 


10.0 


Urine 

Meconium 

Co 2 


. 48.0) 
. 51.0 \ 
. 96.0 J 

195.0 


185 


2 


91.5 


Urine 


. 53.0 ] 






Meconium 

Faeces 

Co 2 


. 23.0 1 

3.0 ( 

. 84.5 J 


72 








163.5 




3 


247.0 




. 172.0) 






Faeces 

Co 2 


3.0 V 

. 82.0 J 


10 








257.0 




4 


337.0 




. 226.0 ) 






Faeces 

Co 2 


2.5 V 
. 93.5 J 


+ 15 








322.0 





Thus, the loss of weight during the first four days is due in great 
part to the lack of sufficient nourishment to compensate for the loss 
through the urine and fasces. 

In order to illustrate more completely the oxidation processes 
in the body, Cammerer has reduced the food and excreta to their 
chemical elements. The C, H, E" and O taken into the body in the 



Infant Fourteen Days Old, Weighing 3500 Grammes. 



Taken into the hody in 
twenty-four hours. 


Water. 


C. 


H. 


N. 


O. 


Ash. 


Milk 

Inspired O. . 


500.0 
70.2 


444.0 


29.5 


4.5 

49.3 


2.0 


18.4 

70.2 

394.7 


1.6 




444.0 




Urine voided . . . 

Faeces 

Co 2 


570.2 

350.0 

7.0 

185.1 


444.0 

347.0 

5.0 

104.1 


29.5 

0.7 

0.8 

22.0 


53.8 

0.1 
0.1 

50.7 


2.0 

1.0 
0.1 


483.3 

0.7 

0.3 

59.0 

405.4 


1.6 

0.5 

0.7 




456.1 




Balance in favor of 
increase of weight 


542.1 


456.1 

28.1 


23.5 
6.0 


50.9 
2.9 


1.1 

0.9 


465.4 
17.9 


1.2 
0.4 



form of nourishment and inhaled oxygen are compared to the same 
elements excreted in the urine, faeces, and the expired air. It is seen 
that in the newborn, as in the adult, fully 93.4 per cent, of the carbon 



MORTALITY AND SUDDEN DEATH IN THE NEWBORN. 1 79 

taken in is excreted in the carbonic-acid gas, the nitrogen being 
excreted for the most part in the urine. Whereas, however, in the 
adult the nitrogen taken in is excreted entirely in the urine and 
fseces ; in the newborn fully half the nitrogen is retained in the body. 
The student may thus see that the loss of weight during the first 
few days is considerable. It has not as yet been accurately deter- 
mined whether an infant nursed from the first day of life on a breast 
secreting abundant milk would lose weight similar to that of the 
newborn nursed on the mother's breast. It is well known that the 
loss of weight is greater in those fed on a substitute than on the 
breast. The further details of loss and increase of weight will be 
found under the heading of Infant-feeding. 

MORTALITY AND SUDDEN DEATH IN THE NEWBORN. 

Sudden death is not uncommon in the first week of life, and, 
according to Snow, fully one-tenth of the race succumb in the first 
month of existence. Modern methods have tended to reduce this 
startling mortality, but the conditions attending the birth of the 
infant are such that there will always be, independent of sepsis of 
any kind, a quota of the newborn which will succumb, either with 
previous symptoms or suddenly, in the first week or first month of 
existence. Eross has found that 9-J per cent, of all children born in 
Europe died in the first four weeks of life. Of these 37 per cent, 
died in the first week, 29 per cent, in the second, 21 per cent, in the 
third, and 13 per cent, in the fourth week. 

The statistics of the different countries vary, as one would nat- 
urally expect, according to the methods of midwifery in vogue. It 
is of interest, however, that, in the United States, Snow, of Buffalo, 
has collected some statistics on this subject in his own city. Of 7290 
births 471 died during the first month. Thus 6.4 per cent, of all the 
children born in Buffalo died during the first four weeks, a death 
rate of 9.3 per cent, of the total mortality. 

If we look for the causes of mortality in early life we may class 
them grossly under those due to (1) immaturity or congenital weak- 
ness, with or without syphilis; (2) malformations which are fatal in 
themselves; (3) asphyxiation and atelectasis ; (4) injuries sustained 
during parturition, such as apoplexies, both cephalic and abdominal: 
(5) septic infections of various kinds. The effect of prolonged and 
difficult labor, abnormal presentations, the application of forceps. 
may cause a cerebral hemorrhage, especially in premature or con- 
genially weak infants, but a difficult labor is nor necessarily an 
etiological factor in these cases, (ov cerebral hemorrhages occur in 
infants who have passed through an apparently normal, or even a 



180 DISEASES OF THE NEWBORN. 

precipitate, labor. It seems that in these cases simple pressure of 
the parts in the parturient canal precipitates a hemorrhage which, 
subsequent to birth, attains an extent which is fatal. 

Spencer found that of 130 infants dying in the first few hours of 
life, 65 per cent, of deaths were due to injuries sustained by the 
brain in the form of congestion and hemorrhages, and he considers 
the forceps, next to abnormal presentations, such as foot and breech, 
as the most frequent etiological factor in producing hemorrhage. 

Hemorrhage and apoplexies of fatal character may occur in the 
liver, suprarenal capsule, and lung, and many children subject to 
cerebral hemorrhages succumb to convulsions in the first hours of 
existence. It must not be forgotten, however, that the most trying 
cases of sudden death in the newborn are those in which infants 
are born after a labor in every respect normal, and who at birth 
present absolutely nothing abnormal physically to the careful and 
practised eye, and who continue in apparent health for twenty- 
four hours to a week, with sudden death as an outcome. These 
cases present absolutely no symptoms to warn the physician of 
the approaching catastrophe. They may nurse in a regular man- 
ner, apparently, the bowels may appear natural in color and con- 
sistence, and even after the death of the infant an inquiry into the 
clinical history of the case fails to reveal any symptom which might 
lead to the detection of the trouble. These cases post-mortem may 
reveal a cerebral hemorrhage or an abdominal umbilical hemor- 
rhage, which previously revealed but few symptoms. I recently saw 
such a case in a premature child, born rather precipitately, which 
continued well and in perfect condition for twenty-four hours, then 
suddenly developed cyanosis, attacks of respiratory apncea, and died 
within a few hours. In this case nothing was revealed post-mortem 
but a slight atelectasis of the lung. Another, in which an infant 
nursed on the breast of a wet-nurse for six days, did not lose weight, 
but rather held its own, nursed vigorously a few hours before death, 
cried but little, slept most of the time, and was found dead in bed, 
with a slight hemorrhage from the nose, on the sixth day. This, in 
all likelihood, was a case of unrecognized sepsis of the newborn. 

In the newborn all cases do not die suddenly. There is in most 
cases marked or slight warning, extending over days or hours before 
the fatal issue. There may be signs of cerebral irritation, but these, 
as a rule, come on suddenly in severe cases. Some time, hours or 
days, after birth, the child may be attacked with cyanosis, it may 
whine or cry without apparent cause, there may be derangement of 
the respirations, irregularly slow pulse; there may be a series of con- 
vulsions, which may end the scene or which may continue for days. 
Sometimes a slight hemorrhage gives rise to no symptoms at all until 



CONGENITAL ANOMALIES. 1 8 1 

later in life, so that we cannot say that hemorrhage always causes 
death in the newborn. 

If meningeal hemorrhage is preceded by the symptoms such as 
have been detailed, a diagnosis can be made, but in cases in which 
these symptoms are absent clinical diagnosis is impossible. As- 
phyxia, atelectasis, and compression of the cord cause a mortality 
of 3.6 per cent, of the total number of deaths in the newborn. In 
congenital atelectasis there may have been an easy labor, but inherent 
weakness and immaturity of the respiratory muscles may cause 
imperfect expansion of the lungs. 

A large proportion of deaths in the newborn infant are the result 
of sepsis. The pathogeny and symptomatology of sepsis will be con- 
sidered under the proper heading, but some of the severest forms of 
sepsis, resulting in arteritis of the umbilical arteries or in a general 
bacterial invasion, give absolutely no symptoms and result in sudden 
death. The conditions at this time of life are particularly favorable, 
as has been repeatedly pointed out in these pages, to the invasion of 
germs, and the avenues of infection are various, as has been dilated 
upon in the chapter on Sepsis in the Newborn. Not only is the 
resistance almost nil, but the progression of the disease is unhampered 
by such conditions as leucocytosis, which obtain later in life, for lack 
of leucocytic reaction and deficient development of the lymphatic 
apparatus is especially characteristic of this period of life. 

In addition to sepsis, sudden death in the newborn may be due 
to forms of respiratory disease, such as bronchitis and pneumonia, 
which have not only escaped observation, but which give absolutely 
no symptoms before the fatal issue supervenes, and are only revealed 
on the postmortem table. Such infections have been dilated upon 
elsewhere. They may originate in foul atmosphere, unclean bedding, 
aspiration of amniotic fluid, and as a result of this, contamination 
by colon bacillus, staphylococci, and streptococci. We will not enlarge 
upon the other forms of sepsis of the gastro-enteric type, but will 
leave that for future consideration in the chapter on Sepsis. Sudden 
death in the newborn, due to hypertrophy of the thymus, is a rarity. 

CONGENITAL ANOMALIES. 

Anomalies of the Scrotum.— The scrotum may be divided into 

halves, separated completely from each other, each with its contained 
testis. There are rarely more than two testes. There may be 
accompanying abnormalities, such as circumscribed hydrocele of the 
cord, lipoma fibrosum, and omenta] structures. Anorchidie is a con- 
dition of rudimentary or lacking testis and adnexa mostly unilateral. 
Ectopia testis abdominalis is a condition in which the testis is found 



182 DISEASES OF THE NEWBORN. 

underneath the skin of the abdomen. Ectopia cruralis testis is a 
condition in which the testis is found at the femoral ring, generally 
with a hernia. Ectopia perinealis testis is a condition in which the 
testis is found in the perineum. 

Retentio Testis. — Retentio testis refers to those cases in which the 
testis remains in the abdominal cavity or in some part of the inguinal 
canal. 

Retentio abdominalis refers to the retention of the testis in the 
abdomen. 

Retentio iliaca, near the internal ring. 

Retentio inguinalis refers to the testis retained in the canal or 
near the external ring. 

Double retention is also called cryptorchism ; single retention is 
spoken of as monorchism. 

These congenital conditions are quite common in children, but 
disappear, as a rule, toward the age of puberty. The cause of the 
congenital anomalies is a lack of development or peritoneal adhesions, 
and their principal interest clinically lies in the fact that they may 
be confounded with hernia of an inguinal type. The retained testis 
of the inguinal variety is apt also to atrophy, inasmuch as it is easily 
exposed to traumatism. Kocher has shown, also, that it is more apt 
to be the seat of new growths, especially carcinoma. 

Diagnosis. — The diagnosis of retained testis, especially of the 
inguinal variety, is not difficult. The mother will invariably call 
attention to the absence of the testis from its usual situation. Exami- 
nation of the scrotum will reveal its absence either on one or both 
sides. By invaginating the scrotum through the inguinal canal, the 
physician, as a rule, will find the testis in some part of the canal or 
at the internal opening in the abdomen as a small globular body. 
Tracing the location of the testis, its absence from the scrotum and 
its presence in the abnormal position mentioned, differentiates it 
from a lymph node or a hernia. Hernia as a result of coughing or 
exertion, such as crying, will descend and increase in size or pro- 
trude from the external ring. Not so with the testis. It may even 
retract higher if pain is experienced. 

Treatment. — There is no treatment for this condition, although 
the French advise the systematic pushing down of the testis into the 
scrotum at certain intervals up to the age of puberty. 

Hydrocele Congenita or Adnata. — This anomaly of the congeni- 
tal type is caused by a lack of closure, of the peritoneal fold, the pars 
vaginalis peritonei. There is a communication of the cavity of the 
tunica vaginalis with the peritoneal cavity to a greater or less extent. 
Serous fluid of the peritoneal cavity may gravitate to the cavity of the 



THE CON GEN IT ALLY WEAK. J 8e5 

tunica vaginalis ; or there may be a free opening into the peritoneal 
cavity, allowing a reposition of the fluid. In such cases the anomaly 
is apt to be confounded with inguinal hernia. The communication 
with the peritoneal cavity may be of filiform size. 

Diagnosis. — The diagnosis from hernia is made possible by the 
fact that in the latter reposition with intestinal gurgle is possible; 
whereas a hydrocele cannot be reduced unless there is an opening 
through to the peritoneal cavity. On gentle percussion a hernia will 
also give tympany. Hernia will increase in size as a result of cough- 
ing or crying. Congenital hydrocele may disappear spontaneously. 
Irregular adhesions in the canal may result in small collections of 
fluid along the course of the spermatic cord, thus forming hydrocele 
of the cord. When there is a communication of the peritoneum with 
the tunica vaginalis, a large hernia may result. 

The diagnosis of hydrocele of the cord in the young infant is 
often required of the physician. In these cases we find a collection 
of fluid around the corcl in its course from the peritoneum to the 
testis. This fluid, however, does not communicate with the cavity 
of the tunica vaginalis testis ; nor can the fluid be replaced, as the 
hernia can, into the abdominal cavity. The fluctuating swelling 
extends from the testis to the external abdominal ring. 

Treatment. — The treatment for congenital hydrocele or hydrocele 
of the cord is that of repeated puncture and withdrawal of the fluid. 
No irritants of any kind should be used in congenital forms of 
hydrocele, inasmuch as peritonitis may result should any anomalous 
opening into the peritoneal cavity exist. 

THE CONGENITALLY WEAK (Premature Infants). 

Infants are congenitally weak who weigh less than 2000 grammes 
(4-J pounds), have a body-length of 42 centimetres, and who, on 
account of a lack of development of the various organs and a 
consequent imperfect performance of their functions, show a dimin- 
ished vital energy. Such infants may be premature, weigh as 
little as 600 grammes (1-J pounds), with a body-length of 21 centi- 
metres, and still live. As a rule, however, any infant weighing 
less than 1000 grammes (2.2 pounds) cannot live. The tem- 
perature must also be considered in the study of the congenitally 
weak, as well as the body- weight, for not only does this factor influ- 
ence the prognosis, but also the management of these cases. Con- 
genital weakness may thus exist to various degrees. 

Etiology. — Prematurity is a most frequent cause o( congenital 
weakness. The early interruption of pregnancy may occur in 
apparently healthy mothers as a result of mechanical influences. 



184 DISEASES OF THE NEWBORN. 

intercurrent infectious disease, diseases of the placenta or uterus, or 
constitutional disease. Congenital weakness may exist in one of 
twins or triplets, the other infants being born strong and well de- 
veloped. Though most frequently found among premature infants, 
congenital weakness may exist in infants born at full term, as a 
result of the debilitating influence of tuberculosis or syphilis in 
the mother on the development of the foetus. The congenitally 
weak are also found among infants who are born at full term, but 
in whom there has been for some reason no complete expansion of 
the lungs and in whom atelectasis results (asphyxia of the newborn). 
Thus, congenital weakness may at times go hand in hand with pre- 
maturity ; at others prematurity is not an essential factor. 

Morbid Anatomy. — Premature infants are underweight according 
to the degree of prematurity. The head is small and globular; the 
pupils still show the pupillary membrane ; the skin is red and 
glistens ; the face is wrinkled ; wool-hair or lanugo covers the body ; 
nails are undeveloped: the external genital organs, the clitoris and 
nymphse, are prominent ; the brain is undeveloped ; the heart and 
vessels present foetal characteristics, such as an open ductus Botalli 
or foramen ovale; the thyroid and thymus glands and the supra- 
renal capsules are large : uric-acicl infarctions are foimd in the kid- 
ney; the intestinal structures and bones are undeveloped. 

If infection occurs the lungs show areas of bronchopneumonia 
with atelectasis ; on the surface of the lungs there are hemorrhagic 
areas resembling infarctions. In other words, there is hemorrhagic 
pneumonia due to infection either by streptococci, staphylococci, 
bacillus coli communis, or pneumococci. The bronchial nodes may 
be enlarged and there may be pericarditis. The intestines, liver, and 
kidney, in addition to being undeveloped, may present lesions similar 
to those found in sepsis. Infections may remain local and limited to 
the point of entrance of the bacteria, or may become general. ^The 
portals of infection are solutions of continuity in the skin, mucous 
membrane of the gastro-enteric tract and respiratory passages which 
allow the entrance of bacteria from the air, garments, or objects 
brought in contact with the infant's hands, linen, or food. 

Symptoms. — The body is spare ; the skin is soft and delicate, uni- 
formly red and transparent, showing plainly the bloodvessels. The 
delicacy of the skin renders it susceptible to traumatism, resulting 
in the formation of erosions. The surface is cool, pale, icteric, 
sometimes cyanotic. Desquamation of the skin, present normally 
in the newborn, is delayed from four to eight weeks. In very 
severe cases there may be sclerema. 

The infant does not cry, but rather whimpers ; the respiratory 
movements are scarcely noticeable, there is muscular inertia, and 



THE CON GEN IT ALLY WEAK. 185 

the infant lies in a torpid condition. The intestine and stomach 
are easily disturbed; the liver performs its function imperfectly, 
and in many of these cases there is icterus. A temperature as 
low as 30° C. (86° F.) may exist and continue for days. These 
infants, if left exposed momentarily, even after a warm bath, 
may experience a serious reduction of temperature. They are 
thus easily chilled, and attain a temperature near the normal only 
with the greatest difficulty. The body-temperature during treatment 
in the incubator may not rise above 36.9° C. (98.4° F.). In those 
infants affected with sclerema the temperature may not rise for days 
above 28° to 35° C. (82.4° to 95° F.) in the rectum. As a direct 
result of the low body-temperature and disturbed metabolic proc- 
esses these infants suffer from cyanosis, which at times is difficult 
to dissipate. 

There is at first a lack of nursing power, and at most 10 or 15 
c.c. of milk are taken at a nursing. The evacuation of the bowels 
takes place very sluggishly, often days apart; meconium persists in 
the gut as long as six to eight days. The urine is passed in much 
diminished quantity, and the loss of weight is more rapid than is 
true of normal infants. 

Should a premature infant develop an infectious bronchopneu- 
monia, the diagnosis is extremely difficult. Percussion can rarely 
establish a dulness of any extent, the respiratory movements are 
feeble, the air scarcely enters the lungs, cyanosis is present, and the 
temperature may be subnormal. The infant will therefore simply fail 
in a general way. There may be an eruption or hemorrhages in the 
skin, and death may take place with general or partial convulsions. 

The congenitally weak infant may, if fed incorrectly, either with 
too much or faulty food (milk), suffer from diarrhoea, which tends not 
only to a reduction of body-weight, but to an increase of weakness. 

Prognosis. — The body-weight, the rectal temperature, and the 
mode of feeding determine the prognosis. 

Of the congenitally weak weighing less than 1200 grammes, but 
few or none are saved; of those weighing 1200 to 1400 grammes, 
40 per cent, are saved; of those weighing 1500 to 1599 grammes. 
86.7 per cent, are saved; and from 2000 to 2500 grammes, 93.6 
per cent, are saved (Budin). 

As an exceptional instance of successful rearing of the congeni- 
tally weak may be mentioned the case of Villemin, who records the 
saving of an infant who at birth weighed only ^^v> grammes 
pounds). 

The influence which the rectal temperature has on the prognosis 
is shown by Budin, who found that of cases weighing less than \^00 
grammes, with a rectal temperature o( 32° C or less, only 2 o\ 103 



186 DISEASES OF THE NEWBORN. 

were saved; of those weighing 1500 to 2000 grammes, with a rectal 
temperature of 32° C, only 1 of 39 was saved; a combined mortality 
of 98 per cent. Therefore the rapid reduction of temperature is an 
important factor in the mortality of these infants. 

The mode of feeding is an important element in the prognosis, 
for the mortality is greater among the congenitally weak or prema- 
ture infants brought up on the bottle than among those reared on 
the breast. 

It is interesting to note the observation of Budin, that of 54 
infants who had at departure from his service weighed 2800 to 3000 
grammes, 31 per cent. died. Of the 54 infants, 24 were fed arti- 
ficially, of whom 41 per cent, died; of 20 fed at the breast, only 
15 per cent. died. 

The causes of death among the congenitally weak are principally 
infectious bronchitis, bronchopneumonia, infectious and epidemic dis- 
ease. Aside from infectious diarrhoea, syphilis and digestive disor- 
ders play an important role as causes of death. 

Management of Congenitally Weak Infants. — In speaking of 
the management of congenitally weak infants the student should un- 
derstand that each country has its favorite method of managing these 
cases. If a premature or congenitally weak infant is born asphyx- 
iated, the treatment is much the same at the start as that detailed in 
the section on asphyxia of the newborn ; but, as intimated, our efforts 
must be directed to saving the congenitally weak, after resuscitation 
methods have succeeded, by maintaining the body-temperature, by 
feeding the infant correctly, and by supporting the heart and respira- 
tion. The weight and the rectal temperature, therefore, not the age 
of the infant at birth, will decide for the most part the line of treat- 
ment, for some infants at full term, as has been stated, are much 
below the normal weight, with a subnormal temperature, and are 
therefore congenitally weak. It would be unsafe to outline— any 
treatment based only on the age of the infant at birth. 

We will first take up the methods of maintaining the body-tem- 
perature. This is done by means of the incubator. 

Incubators. — The simplest model of an efficient incubator for 
maintaining the temperature of the congenitally weak is that first 
introduced by Tarnier. Though many complicated pieces of appa- 
ratus have been constructed since the time of this clinician, none has 
surpassed his model in efficiency. The most efficient incubators are 
made of metal or are porcelain-lined, simple in construction, and 
allow of thorough ventilation while maintaining the desired degree 
of temperature. Infections being common at this period, an incu- 
bator should be so constructed that it can be easily cleaned and 
subjected to sterilization before use. Incubators made entirely of 
wood are therefore useless, if not dangerous. 



THE CON GEN IT ALLY WEAK. 



187 



Of the elaborate incubators that of Lion (Fig. 27) has given the 
greatest number of successes. This elaborate apparatus can be well 
ventilated and equably heated. The heat is supplied by radiation. 
In an emergency, any kind of tin-lined box or a basket padded with 
cotton, supplied with warming bottles, and so protected on top as not 
to admit of a too rapid escape of the air, answers the purpose of a 

Fig. 27. 




Lion Incubator. 



more elaborate apparatus. Tn fact, Chapin lias shown that with 
very elaborate apparatus he has had less brilliant results than with 
simpler means. The cause of his ill-success Lies in the fact that 
complicated apparatus is very difficull to cleanse after having once 
been infected. 



188 DISEASES OF THE NEWBOEN. 

The indications for the employment of any form of incubator 
are: (a) Weight, the infant weighing 2000 grammes or less. Infants 
weighing 1800 grammes if vigorous, may be reared without an incu- 
bator, (b) Subnormal rectal temperature, as has been emphasized 
elsewhere, (c) Cyanosis or sclerema. 

The temperature at which the interior of the incubator should be 
maintained is of the greatest importance. It has been customary to 
keep the temperature of the interior of the incubator a little higher 
than that of the infant, with the idea that in this way the heat 
which is transmitted to the body of the infant is necessary. Later 
investigations have proved that an infant with a rectal temperature 
of 30°-32° C. (86.6° to 89.6° F.) will be more comfortable and 
thrive better in an incubator kept at 25°-26° C. (77° to 78.8° F.) 
than in one in which the temperature is 35°-37° C, (95° to 98.6° 
F.), as was formerly practised. Therefore the interior of the incu- 
bator should have a temperature of 25° to 26° C. (77° to 79° F.). 

An infant brought up in an incubator should increase regularly in 
weight and strength. It should have one or two movements daily, 
and should take its nourishment at regular intervals. If it loses 
in weight, remains cold, cannot be roused, breathes superficially,, 
develops cyanosis, dyspnoea, diarrhoea, cough, or vomiting, the outlook 
is grave. Even should the infant thrive, it must not be allowed to 
remain torpid. It should be taken out of the incubator cautiously, 
and, if the respiratory movements are shallow, should from time to 
time be caused to cry by mild irritation. In this way the lungs are 
expanded and become aerated. The infant should be turned on it? 
side and kept lying in that position, thus avoiding hypostasis in the 
lower or posterior part of the lungs. If vomiting occurs, the food 
should be modified, peptonized, or reduced in quantity, or the inter- 
vals of feeding lengthened. Cyanosis, as has been mentioned, is met 
by friction and flagellation. In carrying this out caution ^nust "Be 
observed as regards the liver, which is quite large at this period and 
easily lacerated. If mucus collects in the throat, it must be cau- 
tiously aspirated by means of a small rubber catheter introduced to 
the back of the pharynx, passing over the epiglottis to the superior 
opening of the larynx. Success in feeding will also aid in overcoming 
the cyanosis. 

Feeding. — The feeding of premature infants is a most difficult 
problem. At this time, as a rule, the infant is unable to grasp the 
breast. Therefore it must be fed with a pipette or a nursing tube 
constructed for this purpose (Fig. 28). In these cases the milk is 
pumped from the breast and transferred to the infant. We must be 
careful not to give too much food, for thereby diarrhoea and vomiting 
may set in ; on the other hand, too little food will only tend to per- 



TEE CONGENITALLY WEAK. 



18<j 



Fig. 28. 




petuate the weakness and cause cyanosis. During the first ten days 
there may be loss of weight, or the weight may remain stationary and 
finally increase. Budin found in feeding these infants that there were 
three sets of cases, in each of which he could estimate the amount of 
food taken daily. In the first set of cases the infants weighed less 
than 1800 grammes and on the second day took 115 grammes 
of nourishment; on the tenth day, 320 grammes. The second set 
of cases were those which ranged from 1800 to 2200 grammes, 
and on the second day took 128 grammes of breast 
milk ; on the tenth day, 410 grammes. The third set 
of cases weighed from 2200 to 2500 grammes, and 
on the second day took 180 grammes of milk; on the 
tenth day, 425 grammes. Thus, the amount of food 
will vary with the weight and must be gradually 
increased in all cases. A small quantity (see 
Infant-feeding) must be given at each feeding, and 
the feedings should be at intervals of one and a 
half hours. 

Feeding by gavage instead of by the pipette was 
first resorted to by Tarnier. It may be said, however, 
that this is scarcely necessary except in very torpid 
infants. 

We must be exceedingly careful in institutions, 
in caring for premature infants, to guard against the 
spread of any form of disease which may attack them. 
A bronchitis in a premature infant is a more serious 
disease than in an infant born at full term with nor- 
mal weight and temperature. This bronchitis is of the 
infectious type and very fatal to premature con- 
genially weak infants. As a rule, it leads to bron- 
chopneumonia and in institutions is apt to spread 
from one weakling to the other. Any epidemic dis- 
ease may attack these infants; prophylaxis therefore plays an im- 
portant role in the prognosis. In institutions a congenitally weak 
infant attacked with bronchitis should immediately be isolated as in 
any other infectious disease. In private practice visitors should not 
be allowed to see these congenitally weak infants and thus infect 
them. Anyone suffering with an ordinary cold should be forbidden 
to come in the vicinity of an incubator. 

Bosi, Giudi, Escherich, and others have proposed the construction 
of incubator wards, in which (he infant should not be exposed to 
the changes of temperature and danger of infection when taken out 
of its crib. It may be slated, however, that there is a greal dis- 
advantage in the construction id' incubator wards, for neither can 




Breck's feeding 
tube for prema- 
ture infants. 



190 DISEASES OF THE NEWBORN. 

infections be avoided any more than in ordinary hospital wards, nor 
can the temperature in a large space be maintained as easily as in 
small chambers; and, finally, the isolation of one little patient from 
another cannot be as complete in an incubator ward as in the indi- 
vidual crib or incubator. 

Bath and Clothing of the Congenitally Weak. — The congenitally 
weak or premature infant is easily chilled, and therefore after birth 
should not be bathed. It should be well anointed with oil, and this 
removed with absorbent cotton in such a manner that the body is left 
clean and free from vernix caseosa or extraneous substances: The 
infant is then wrapped in one layer of sterilized cotton covering the 
trunk and the extremities. Over this is sewed a jacket of sterile gauze 
so as to encase the whole body. The buttocks and genitals, however, 
are left free, so that any meconium or urine that is passed may be 
caught by cotton placed against these parts. In this way the infant 
is not chilled when taken from the incubator to be fed or washed. 

Ultimate Fate of the Incubator Infant. — Some of the best de- 
veloped men and women came into the world congenitally weak, so 
that the physician should spare no effort to bring about success, no 
matter how weak the infant may appear at the outset. Especially 
encouraging are the results obtained with the congenitally weak when 
it has been possible to feed the infant from the beginning to the termi- 
nation of infancy with breast milk. The statistics of Budin, quoted 
elsewhere, show conclusively that of the premature infants discharged 
from his institution with a weight of 2800 to 3000 grammes, those 
who fared best were the breast-fed infants, of whom only 15 per cent, 
died before attaining maturity, whereas 41 per cent, of the bottle-fed 
infants died during infancy. 

The physician will have an easier task, if, in addition to the incu- 
bator, he makes every effort to obtain human milk for the weakling. 

Feeding of the Congenitally Weak and Premature Infants. — 
Breast-feeding. — The ideal method of feeding the congenitally weak, 
and the one which is attended with the greatest number of successes, 
is that with breast milk. There are, however, some facts which must 
not be lost sight of in feeding the congenitally weak on the breast. 
Their suction power is much below that of the normal infant born at 
full term. In some cases the congenitally weak infant is unable to 
nurse at all. If the mother and not a wet-nurse is to nourish the 
infant, the milk must be pumped from the breast and fed to the child 
by means of the Breck Feeder, if the infant is unable to nurse the 
breast directly. In extreme cases the infant will not even have the 
power to swallow the milk pumped from the breast and fed to it with 
a feeder. Under such circumstances the milk must be carefully fed 
to the infant, by means of gavage, four or five times in the twenty- 



THE CONGENITALLY WEAK. 1 9 1 

four hours. As a rule, however, the mother of a premature infant 
will, if the infant is born much before full term, have very little milk 
in her breast. In such a case, it is advisable to obtain a wet-nurse 
whose milk is uniform, and whose child is at least one or two months 
of age. Should a wet-nurse not be available at this time, the infant 
may be placed on modified milk until the milk appears in the mother's 
breast. A wet-nurse who nurses a congenitally weak infant exclu- 
sively will lose her milk gradually, because the congenitally weak in- 
fant, though it nurses the breast, exerts so little suction power that the 
normal excitation to continued glandular activity of the breast is lack- 
ing and the milk gradually diminishes in quantity, finally ceasing to 
be secreted. It is well, therefore, to allow the wet-nurse to nurse her 
own infant while supplying the excess of milk to the congenitally 
weak infant she is caring for. Under this arrangement there need 
be no fear that either infant will suffer from an insufficiency of milk, 
inasmuch as the additional stimulus given by the two infants to the 
gland will result in an increased secretion of milk, a fact which has 
been repeatedly proved. 

The amount of breast milk which a congenitally weak or pre- 
mature infant will take from the breast will vary widely with the 
strength, age, and weight of the infant. As a rule, the amount will 
vary from 200 to 500 c.c. daily. The nursings should be at intervals 
of an hour to an hour and a half. The younger the infant the more 
frequent should be nursings and the smaller the quantity at each 
feeding. If the infant is unable to nurse the breast, the milk may 
be pumped off and given in a bottle or feeder to the infant ; or is 
given, as has been stated, by gavage. It may happen, as has been 
intimated, that the mother, after the birth of a premature infant, has 
very little milk in her breast. If such an infant is placed tempor- 
arily on modified milk, the milk may appear in the mother's breast 
after a week or two, and the gland may be excited to increased secre- 
tion by placing the infant at the breast, especially if it be not too 
premature or weak. 

Artificial Feeding. — The feeding of the congenitally weak or pre- 
mature infant with modified milk is a very difficult task, inasmuch 
as comparatively few facts are at our disposal to-day as to the success 
of this mode of feeding. We know that the success attending the 
feeding of the congenitally weak or premature infant on cows' milk 
is even less than that of feeding the normal newborn infant. We 
will illustrate the feeding of these infants by taking as an example 
a premature or congenitally weak infant born at seven and a half 
months of pregnancy. Such an infant is first placed upon a mixture 
containing 1 per cent, of fat, 0.25 per cent, of proteids, and 5 or t> 
per cent, of sugar. The infant is given 10 c.c, or lV, drachms, ar 



192 DISEASES OF THE NEWBORN. 

each feeding, the intervals between the feedings being one hour. 
Twelve feedings are given in the twenty-four hours, rest being given 
for the remaining twelve hours. 

After a week of extra-uterine life the percentage of proteids is 
doubled, the fat and sugar remaining the same. From the fifteenth 
day of life the infant will be taking -J ounce at each feeding, twelve 
feedings being given in the twenty-four hours. After the fifteenth 
day the proteids may be increased, so that from the thirtieth day of 
life the infant will be taking a mixture of 1 to 1.5 per cent, of fat, 
0.75 per cent, of proteids, and 6 per cent, of sugar, 1-J ounces at each 
feeding, with intervals of two hours between the feedings. Ten or 
twelve feedings are given in the twenty-four hours. At this time the 
infant will have approached the age of a full-term infant. We should 
now be cautious not to increase the percentages or strength of the 
mixture too rapidly, but rather to let them remain stationary and 
watch the increase of weight. If the weight increases along physio- 
logical lines, we are then guided by the same considerations which 
would obtain with an infant born at full term. 

Congenitally weak infants, fed upon modified milk mixtures, who 
show dyspeptic disturbances, evidenced by green stools or white curds 
in the movements, should a wet-nurse be unavailable, are fed with a 
peptonized mixture. The peptonizing is carried out with good results 
by the process detailed elsewhere. 

Mixed Feeding. — This is a combination of breast and bottle-feeding 
in those cases in which the breast does not yield sufficient milk and 
the weight of the infant remains stationary. This is seen in cases 
of twins nursed by the mother or even by a wet-nurse. In such cases 
several feedings by means of the bottle may be given daily in addition 
to the breast. 

The Amount of Food Taken by the Congenitally Weak Infant 
Daily. — It has been shown conclusively that the congenitally weak 
infant at the breast will consume daily approximately one-fifth of its 
own weight of breast milk. The so-called normal quantities of breast 
milk taken by the congenitally weak infants, carefully weighed before 
and after nursing, are found by Budin to be as follows : 

Infants of 1000 grammes, 200 grammes. 



c 


1500 


250 


( 


1800 < 


' 360 


( 


2000 < 


< 400 


I 


' 2500 ' 


1 500 


I 


: 3000 ' 


1 600 



The amount of breast milk taken daily in the first ten days of 
life gradually increase, as stated, from 115 grammes, taken the second 
day by an infant of 1800 grammes, to 320 grammes on the tenth 



ASPHYXIA OF THE NEWBORN INFANT. 193 

day. An infant weighing 2200 to 2500 grammes will take on the 
average 180 grammes, taken the second day, to 425 on the tenth day, 
its normal quantity of food. 

These quantities of breast milk consumed by the congenitally 
weak will be seen to exceed or equal in amount what the normal 
infant at full term consumes. This proves distinctly what has 
always been insisted upon by the writer that the amount of food 
necessary to the infant is determined by the needs of the body and 
not by any arbitrary standard of stomach capacity. In other words, 
the congenitally weak infant, though under weight, really needs more 
calories of foodstuffs per kilogramme of body-weight than the full- 
term infant, because it uses up more heat units of energy, having 
more extent of body surface exposed for its weight than the normal 
full-term infant. Unless the calories, in the form of increased nour- 
ishment, are supplied to these congenitally weak and premature 
infants, they fail to thrive, become cyanotic, and die. Thus, when 
feeding these infants with cows' milk, modified or peptonized, it must 
not be forgotten that the above principles hold true, and that the 
amount of breast milk consumed by the congenitally weak is a better 
guide as to the necessary quantity of artificial food to be given these 
infants than the weight or stomach capacity. On the other hand, if 
the congenitally weak are fed in excess of their needs, there result 
vomiting and diarrhoea, with loss of weight or stationary weight. 

ASPHYXIA OF THE NEWBORN INFANT. 

Definition and Etiology. — Asphyxia is a condition produced by an 
interference with the oxygenation of the blood. In the uterus respi- 
ration is effected through the placenta. If the placenta is separated 
wholly or in part from its uterine attachment, or the circulation in 
this organ is interfered with, the disturbance of the normal conditions 
causes efforts at respiration, the result of deficient oxygenation of the 
blood. Asphyxia may thus be produced by tonic contraction of the 
uterus, premature rupture of the membranes and escape of the liquor 
amnii, asphyxiation of the mother, a hemorrhage, the administration 
of drugs to the mother intra-partum, pressure on the cord, injury to 
the head intra-partum, or through pressure on the vagus intra-partum, 
with disturbance of the respiratory centres. If the placenta is sepa- 
rated prematurely there are consequent efforts at respiration, during 
which liquor amnii or mucus may be aspirated and asphyxia thus 
produced. In the extra-uterine form of asphyxiation the infant is 
born and makes efforts at respiration; bin inherent constitutional 
weakness, weakness oi' the respiratory muscles, deformity o\ the chest. 
or disease of the lungs renders full expansion of the lungs impossible, 

18 



194 DISEASES OF THE NEWBORN. 

Syphilitic disease of the lungs, tumors of the lungs, or affections of 
the pleura may have the same effect. 

Morbid Anatomy. — The blood in infants who have died asphyxi- 
ated is thin and fluid. The right heart and large vessels are filled 
with blood, as are also the sinuses of the diira mater, pia mater, and 
liver. The liver is dark and bluish in tint. Punctate hemorrhages 
are found in the pia mater, pleura, pericardium, peritoneum, liver, 
kidney, retroperitoneal connective tissue, uterus, kidneys, suprarenal 
capsule, and retina. There is a serosanguinolent effusion into the 
cavity of the peritoneum, pleura, and pericardium. (Edema of the 
extremities, scrotum, and connective tissue about the umbilical ves- 
sels and pia mater is present. The lungs are dark red and heavy. 
Ecchymoses are seen underneath the pleura and pericardium. In 
the lungs there are islands v of aerated tissue and areas of atelectasis, 
even though the infant has breathed. The trachea and bronchi may 
be filled with liquor amnii, mucus, or meconium; the latter is rec- 
ognized by the presence of lanugo, epithelial scales, fatty crystals, 
bilirubin, and cholesterin crystals. The stomach may be filled with 
air or meconium. 

Symptoms. — If in a normal state when born, the infant breathes 
energetically, cries lustily, and opens its eyes, and the skin., which is 
of a purple hue at first, rapidly assumes a pinkish tint. If asphyxia 
be present, however, we may have two sets of symptoms, which are 
characteristic of two forms of this condition. 

In the first form, or early stage, of asphyxia, the skin has a 
bluish or pinkish-blue tint. The face is swollen and the conjunctivae 
injected. The infant does not move the extremities. The muscu- 
lature retains its tonicity; the heart action is slow but forcible; the 
apex beat is apparent to the eye; the vessels of the cord are filled 
with blood and pulsate; the respiratory efforts may be shallow and 
infrequent, or absent ; the infant can be roused and caused to cry. 

In the more advanced form of asphyxia the face is pale and waxy, 
the lips are cyanosed; the extremities hang lax, and the muscular 
tonus is absent; the head falls to one side and the jaw drops. There 
is no attempt at respiration or only imperfect gasping efforts. The 
infant has a corpse-like appearance. The heart-beat is weak though 
palpable. The vessels of the cord are collapsed and pulsation is 
weak. If a few gasps of respiration are made at birth, these soon 
cease. On attempt at respiration the ribs are retracted, but the 
muscles of the face are immobile. Air is prevented from entering 
the lung by the inspired mucus. The reflexes are absent. If un- 
treated, infants in this stage of asphyxia die. If they live, efforts 
at respiration must be repeatedly encouraged, else the infants relapse 
into a torpid condition and the respirations become superficial. 



ASPHYXIA OF THE NEWBORN INFANT. 195 

Diagnosis. — Asphyxia must be differentiated from the effects of 
pressure due to cerebral hemorrhage occurring at birth during a pro- 
longed labor or application of the forceps. In a large hemorrhage 
death is rapid, but in slight hemorrhage it may be difficult to make 
a differential diagnosis. If there is a hemorrhage on the surface of 
the brain, the symptoms may closely resemble those of asphyxia. 
The breathing is very superficial; the infant lapses into sopor; the 
pulse may at first be slow and subsequently rapid. There may be 
occasional convulsions. The fontanelle in cases of hemorrhage on 
the surface of the brain has a peculiar hard feel. The subsequent 
history only will clear up these cases. Asphyxia may be combined 
with cerebral hemorrhage. The history of the birth as to the use of 
forceps and the duration of the labor will aid us. If after irritation 
the infant relapses into sopor, if the pulse continues slow and there 
are repeated convulsions, we may assume the existence of hemorrhage. 

Prognosis. — The prognosis in all forms of asphyxia, if untreated, 
is grave, and in the second stage is necessarily fatal. If treated, 
however, the majority of these cases recover, especially in the first 
stage. As to the cases of the second stage, much will depend on the 
duration of the second stage of labor and the compression of the cord. 
The cases in which cerebral hemorrhage of any severity is combined 
with the asphyxia are grave. Little and Mitchell have demonstrated 
that idiocy may subsequently develop in these cases. 

Treatment. — The treatment of asphyxia is directed to clearing the 
air-passages as much as possible of obstructing mucuSj increasing the 
number of respirations, and stimulating the circulation. The mucus 
and aspirated meconium are quickly but gently removed from the 
month by the finger. 

An instrument has been devised for the aspiration of mucus from 
the upper part of the larynx and trachea ; but this instrument is not 
always at hand, and a sterilized catheter, No. 7 French, can be easily 
introduced to the rima glottidis, and the mucus thus aspirated by 
means of mouth suction. Care, of course, must be taken by the 
nurse or physician not to infect the catheter. To avoid this a small 
piece of glass tubing may be attached to the distal end, and in the 
lumen of the tubing a small piece of cotton may be loosely plugged; 
thus saliva and bacteria from the mouth will nol enter the catheter. 
Introduction of the catheter into the trachea is hardly necessary. 

In order to stimulate the surface, the infant is quickly placed in 
a bath at 40.5° C. (105° F.), and then in a cold bath, thence trans- 
ferred to a. warm blanket and rubbed thoroughly dry. After this 
the infant is, if possible, roused by striking the buttocks quite sharply. 
If these, methods do not cause the infanl to cry and breathe deeply, 
artificial respiration by the Schultze method should bo resorted to. 



196 DISEASES OF THE NEWBORN. 

The operator, standing with his body well balanced, grasps the infant 
by the shoulders, the thumbs being on the anterior aspect of the 
thorax, the index fingers in the axilla?, and the other fingers on the 
back of the chest. The head is supported by the ulnar side of the 
wrists. The operator allows the infant to hang down from his hands 
between his legs. The infant is then raised or swung upward above 
the level of the operator's head to the vertical, so that the lower part 
of the trunk of the infant is bent on the thorax. The thorax is thus 
compressed, causing passive expiration. The infant is held for an 
instant in this position, and then swung down to the original hanging 
position. Passive inspiration is thus performed. 

The Schultze manoeuvre should be repeated at the rate of about 
ten times a minute, at intervals of several seconds. Care must be 
exercised not to injure the thorax by pressure of the thumbs or the 
other fingers, the infant being swung on the index fingers. After 
applying the Schultze method as above for a few minutes the infant 
is given a warm bath, and, if respiration is not completely established, 
the swingings are repeated. By this method the bronchi and mouth 
are freed from mucus, meconium, and liquor amnii, if present. The 
Laborde method is that by which traction is made on the tongue ten 
or twelve times a minute. The infant is laid on a flat surface with a 
folded towel placed between the shoulders, and the tongue is rhyth- 
mically drawn forward by means of a forceps and allowed to recede a 
number of times, corresponding to the normal number of respirations. 

The mouth-to-mouth method consists in first clearing the upper 
air-passages of mucus. The operator then forcibly blows into the 
mouth of the infant. The chest of the infant is then compressed 
to force out the air (expiration of the infant). This procedure is 
repeated as often as sixteen times a minute. 

The Dew method seeks to accomplish the same result as the 
Schultze method, but by simpler means. The infant is grasped by 
the one hand at the nape of the neck, and by the other hand at the 
knees. The thighs rest in the palm of the hand. The thorax is 
flexed on the abdomen, and then extension is performed. Alternate 
expiration and inspiration take place. Inflation of the lungs by 
means of instruments introduced into the larynx is dangerous. There 
are other methods of artificial respiration which may be resorted to, 
such as the Marshall-Hall method, but, on the whole, the Schultze 
procedure seems the most effective. 

The danger in all cases is in abandoning efforts at resuscitation 
too early. We should persist in our efforts as long as the heart 
action continues. After the infant has been brought out of the stage 
of severe asphyxia there is always clanger of relapse into a soporous 
state. In this condition flagellation on the buttocks at regular inter- 
vals may be necessary for days. 



ASPHYXIA SUBSEQUENT TO BlliTE. 197 

In some cases, even after resuscitation has taken place, mucus 
will continue to collect in the upper air-passages. In other words, on 
account of cardiac weakness there is a persistent pulmonary oedema. 
In such cases tracheal mucus will collect in the upper part of the 
glottis, and I have seen brilliant results follow the occasional intro- 
duction into the upper part of the glottis of the catheter for the 
removal of this mucus by means of suction. I have made use of this 
procedure at very short intervals throughout the twenty-four hours 
with excellent results. 

In cases of asphyxia the after-treatment is as important as the 
immediate measures. The infant must be constantly watched. If 
the respirations become too shallow, the infant is gently flagellated; 
and when mucus collects in the throat, it is removed. 

One of the best drugs to help us with these weakly infants is the 
ammonium carbonate (-J grain) given every two hours, with or with- 
out strychnia sulphate (Vsooth of a grain every three hours). The 
infant must be kept warm and carefully fed. Some of these infants 
will not nurse, either on account of inherent weakness or paralysis 
of the tongue, caused by pressure of the forceps, and much patience 
must be exercised. If the tongue has been injured or the hypo- 
glossal nerve pressed upon during birth, one side of the tongue may 
be deflected, and at each feeding the food may find its way into the 
upper part of the glottis, causing spasms of coughing and cyanosis. 
In these cases the nurse will discover that the infant can be fed in a 
certain posture more successfully than in another, or with a pipette 
instead of the nursing bottle. If the cyanotic attacks are frequent 
oxygen must be given almost continuously for hours. After being* 
worked over for days, such infants may make a good recovery or 
die and show extensive atelectasis in spite of the fact that respiration 
has occurred. 

ASPHYXIA SUBSEQUENT TO BIRTH. 

In these cases there is no disturbance of the placental circulation 
previous to the birth of the infant, and therefore no asphyxia. 
Asphyxia appears after birth as a result of some abnormality in 
the respiratory apparatus or of disease of the lung, such as syphilitic 
hepatization; of pleural exudate; o( compression of the air-passages 
by a struma; or of defects of the diaphragm or deficient development 
of the lungs. In some cases there may have been injury or compres- 
sion in the vicinity of the respiratory centre. 

Prematurity carries with it a pliable condition o( the ribs and 
weakness of the respiratory muscles, an msufficienl development of 
the respiratory centre, ami foetal atelectasis, which give rise to a state 



198 DISEASES OF THE NEWBORN. 

of asphyxia. The more premature the infant the more pronounced 
are these conditions. 

Symptoms. — The infant makes no decided effort at respiration 
after birth. Inspiration is absent or is hardly noticeable and shal- 
low. Rales are absent. The vessels in the umbilical cord are filled 
with blood and pulsate distinctly. The heart has a normal frequency 
at first ; then the contractions become slower and may eventually be 
increased in frequency. The skin is bluish-red in color ; the extrem- 
ities are cool. If there is any disease or deformity of the lung, the 
infant dies soon after birth. These cases are only of scientific 
interest. Of more importance to the physician is the premature 
infant normal in all respects save in the fact of its expulsion from 
the uterus before term. 

Premature infants at the sixth, seventh, or eighth month are not 
all born debilitated, nor are all debilitated infants necessarily prema- 
ture. There are infants born at the eighth month which are as easily 
reared as at full term. (See The Congenitally Weak.) 

ATELECTASIS OF THE LUNGS. 

This condition has been referred to in the section on Asphyxia. 
Atelectasis, or collapse of the lung, may be congenital or acquired. 
In the congenital variety the infant is either weakly or born prema- 
turely. The respiratory muscles do not possess sufficient tonus to 
inflate the lung. The result is that the lung remains in the collapsed 
foetal state. In the acquired form the lung cannot expand, as a result 
of obstructions of the bronchi or alveoli, compression of the lung by 
an exudate in the pleura, deformity of the vertebral column, or 
aneurysm of the aorta. 

Etiology. — The lung at birth is compact, the alveoli being col- 
lapsed. The respiratory efforts inflate the alveoli, and the lung 
unfolds gradually, as described elsewhere. If after birth the respira- 
tory efforts are insufficient and the bronchi obstructed, or parts of the 
lung compressed or uninflatable, then a greater or less number of the 
lobuli remain uninflated and atelectasis results. 

If part of the lung which is functionating is thrown out of action 
from any cause, an acquired atelectasis results. This may result 
either from compression (compression atelectasis) or from obstruc- 
tion (obstructive atelectasis). A bronchus may be closed or the 
alveoli may be filled with fluid masses. Atelectasis may result from 
an accumulation of fluid or air in the pleura, or from an inability 
of the diaphragm to act in consequence of curvature of the spine, 
aortic aneurysm, or contracture of the pleura with thickening. 

If the whole lung is involved, it is pressed against the spine, con- 



ATELECTASIS OF THE LUNGS. 199 

densed and tough, devoid of air, of a pale-red color or pigmented. 
The areas of partial atelectasis have the same characteristics, but are 
redder and filled with blood. If a bronchus or bronchiole is ob- 
structed, the lung collapses and returns to the foetal state. Tt becomes 
the seat of passive congestion, so that the atelectatic area is bluish-red 
in color. Obstructive atelectasis is quite frequent, and is seen accom- 
panying any inflammatory process of the swollen bronchi. The 
bluish-red atelectatic areas are seen on the surface of the lung to 
alternate with the red areas containing air. Congenital atelectasis 
reveals portions of the lung as firm, non-crepitant, dark-blue, de- 
pressed areas with a smooth surface on section. These areas can be 
inflated, and then cannot be distinguished from the surrounding lung. 
Inflammatory atelectasis shows the same appearance. At autopsies 
on children dying of inflammatory disease of the lung, these areas of 
atelectasis are seen more frequently the younger the subject. Kachitic 
children are especially subject to atelectasis, on account of their 
inability to inflate the lung completely. 

Symptoms. — The symptoms of atelectasis are not always clearly 
defined. As a rule, the infants, if premature, are weak ; their torpid 
state has been described in the section on the Congenitally Weak. 
On the other hand, should atelectasis develop some time after birth 
as a result of inflammation and plugging of the smaller bronchi, we 
shall have the combined physical sign of atelectasis, bronchitis, and 
possibly bronchopneumonia. In this class of cases the physical signs 
are as follows : 

Inspection. — There is intense dyspnoea ; the lower ribs are re- 
tracted, and the efforts at inspiration are labored and move the upper 
part of the thorax less than the lower portion. The surface is pale 
and sometimes cyanosed. Efforts at coughing are ineffectual, but 
may bring up a frothy, clear expectoration which adheres to the lips. 
Sometimes the breathing is quite irregular and catchy, or very shal- 
low ; at times *the infant seems to cease breathing. 

Palpation. — Palpation is negative except where rales are abun- 
dant, when a fine rhonchal fremitus is present. There is little or no 
vocal fremitus ; it may be increased or it may be diminished, espe- 
cially in areas designated vesiculotympanitic. 

Percussion. — Percussion reveals distinct small areas of dullness 
with a tympanitic note, slight dulness or marked dulness. especially 
if areas of collapse are present with pneumonia. Sometimes the note 
over the rest of the thorax, behind especially, is vesiculotympanitic. 
It the areas of collapse are small, no dulness is elicited. 

Auscultation, — In areas situated at the ajvx or toward the base 
of the lung the air does not seem to enter freely on inspiration, and 
the expiratory sound is hardly audible (collapse o\ area) or absent. 
Breathing is otherwise puerile or exaggerated, rarely bronchial. 



200 DISEASES OF THE NEWBORN. 

Very fine subcrepitant rales are heard in various parts of the 
lung. Crepitant rales are very distinctly heard in other areas, and 
are distinguished from the coarser subcrepitant rales by their fine 
quality. Areas of pneumonia can thus be recognized by the fine 
crepitations ; the atelectasis, by the absence of respiratory sounds and 
dulness. Voice sounds vary greatly. When the infant cries the 
vocal resonance may seem increased, and again normal; or if the 
pneumonic area is extensive and is in the vicinity of a large bronchus, 
we mav have tubular resonance. 

Temperature. — Temperature is often normal or subnormal; later, 
it may be elevated. 

Convulsions. — Convulsions are common in atelectasis ; in fact, 
they are peculiar to the disease. They are repeated at frequent in- 
tervals, and an infant may have three or four attacks of general con- 
vulsions in the course of the twenty-four hours. At the onset of the 
convulsions the cyanosis increases. 

Diagnosis. — The diagnosis is not possible if the area of collapse 
of the lung be small. If of considerable extent and giving rise to 
physical signs, the diagnosis may be made. 

As a rule, the congenital forms of atelectasis are more extensive 
than the acquired forms, and thus can be more readily detected. 

The diagnosis of post-natal congenital atelectasis will depend upon : 

Convulsions. — Given the case of a newborn infant delivered with- 
out forceps or force, in the absence of signs of any other disease, such 
as hemorrhage on the surface of the brain, the presence of repeated 
convulsions, with cyanosis and dyspnoea in the intervals, the possi- 
bility of atelectasis should be considered. 

The presence of areas of slight dulness, or tympanitic dulness, or 
vesiculo-tympanitic resonance all over the chest. 

Fine subcrepitant rales. 

Still finer crepitant rales. 

Areas in which the air enters incompletely. 

Prognosis. — There is no reason why an atelectatic area of the con- 
genital variety should not return to the normal if the cause of its 
existence is removed and the infant regains power to inflate the lung. 
The same may be said of the acquired form of atelectasis. 

Treatment. — The treatment must be directed toward stimulating 
the heart and increasing the respiratory efforts if the infant is weak 
or premature. If the heart is weak, the treatment is much the same 
as in bronchopneumonia. If the infant does not breathe satisfac- 
torily, it is well to make it cry vigorously several times in the twenty- 
four hours, so that the collapsed area of lung may be inflated and the 
mucus in the bronchi expelled. Unless made to cry, these infants lie 
torpid and hardly seem to breathe. The areas of atelectasis are thus 



SEPTIC INFECTION OF THE NEWBORN INFANT. 201 

increased. If the temperature is subnormal and the infant seems 
chilled, we may stimulate it by the application of heat externally, 
either by means of warm baths, hot-water bottles, or an incubator. 

SEPTIC INFECTION OF THE NEWBORN INFANT. 

Our views on the subject of septic infection of the newborn have 
undergone considerable change in the last decade. The former clas- 
sification of certain processes, such as pyaemia, septicopyemia, and 
pyogenic infection, has given way to a greater or less extent to 
broader views. 

By septic infections are meant certain general phenomena pro- 
duced by bacterial toxins, or by the entry of bacteria into the body 
by way of the blood or lymphatic channels. The newborn infant 
is particularly susceptible to infection. At this period of life the 
ordinary means of defence are lacking, the lymph nodes and spleen 
are undeveloped, the skin is in a very vulnerable state and is a ready 
avenue of entrance for bacteria, as are also the mucous membranes. 
The lack of febrile reaction, also, demonstrates that in the newborn 
there is little resistance against the invasion of bacteria. Septic 
infections may appear under the semblance of a diarrhoea, bronchitis, 
pneumonia, hemorrhagic conditions, such as Winckel's or Buhl's dis- 
ease, and dermatitis exfoliativa, all of which are really manifesta- 
tions of sepsis. 

Etiology. — The most frequent causes of septic infection are the 
pyogenic bacteria, the streptococci and staphylococci. Following 
these in order of importance are the bacilli of the coli group, the 
pneumococci, bacilli of general hemorrhagic infection (Babes), the 
bacillus pyocyaneus (Neumann), the capsule bacillus of Dungern, 
the bacillus enteritidis (Gartner), found in hemorrhagic affections 
resembling Winckel's disease, and the bacillus of Finkelstein, found 
also in hemorrhagic conditions. The bacteria exist in the air of 
hospital wards (Emmerich, Babes, Gartner, Prudden"). They are 
found in the normal breast milk (Neumann), and in the milk of 
breasts which are the seat of ulceration, fissure, or abscess. The body 
of the mother, the lochia, and also the liquor amnii after rupture of 
the membranes, are all sources whence bacteria may gain access 10 
the body of the newborn infant. As a rare source of infection may 
be mentioned the incubator in which septic cases have been nursed 
(Allard). The bath-water has been the means oi' causing epidemics 
of dermatitis exfoliativa and Winckel's disease among infants in 
institutions. 

Hetero-in feci ion may also bo mentioned, sm'li as obtains at the 
hands of the accoucheur, from unclean instruments and dressings. 



202 DISEASES OF THE NEWBOEN. 

Among the auto-infections may be mentioned the conditions which 
obtain in the skin of the infant, which is in process of desquamation. 
Deprived of its horny layer, which is absent in the newborn, bacteria 
can penetrate the sudoriparous and sebaceous follicles. Thus, any 
pustule may give rise to a general or local process. 

Umbilical Site. — The umbilical site is not considered as frequent 
an avenue of infection as in former days when puerperal disease was 
more common. To-day we have occasional epidemics of umbilical 
as well as other forms of infection; but with modern methods this 
form of infection has become more and more infrequent. 

Bacteria or their toxins may thus gain access to the body through 
the intact or wounded skin, the umbilicus, the mucous membranes 
(buccal or pharyngeal), through the lungs in the respired air, through 
the digestive tract by means of the food, through the conjunctivae and 
the ears, and finally through the genital tract. 

Respiratory autoinfections occur through the aspiration of liquor 
amnii or vaginal secretions. Bacteria may gain access through a 
minute loss of the lining epithelium of the respiratory tract. 

Digestive Infections. — These must be regarded as rare. The 
manner in which the bacteria gain access to the circulation from the 
gut has been demonstrated by Booker and Escherich. They have 
shown that streptococci may gain access to the general circulation by 
way of lesions of the mucous membrane of the gut. 

Conjunctival Infection. — Conjunctival infection, except in specific 
cases, is rare. 

Otogenic Infection. — The ears may be the seat of septic infection, 
for pus has been found in the ear of the newborn, and thence has 
entered the general circulation through infection of the lateral sinus, 
causing sinus thrombosis, meningitis, and encephalitis. 

Urogenital Infection. — Thrs may occur by way of the urogenital 
tract. As first pointed out by Epstein, an inflammation of the vagina, 
bladder, or kidneys may be a starting-point of general infection. 

Among the predisposing causes of infection of the newborn must 
be considered congenital weakness. Thus, the greatest number of 
cases occur among the weakly infants of syphilitic or tuberculous 
parentage, premature infants, and those possessing birth anomalies. 

Symptoms. — It is impossible to particularize any form of sepsis so 
far as the general symptoms are concerned. The reaction in the newborn 
infant is so imperfect and the signs are so equivocal that it is often 
only at the autopsy table that the nature of the lesion is determined. 
It will be convenient, therefore, simply to enumerate the objective 
changes noted in the various structures of the body in this disease. 

Skin. — The skin may be dry, or the seat of localized oedema or 
sclerema. It may be the seat of erythema, either on the body or on 



PLATE VII 




Sepsis in the Newborn Infant. Suppuration of the 
right knee-joint. Osteomyelitis of the epiphyses of the 
bones forming the joint. 



SEPTIC INFECTION OF TEE NEWBORN INFANT. ZU3 

the extensor surface of the arms or hands. There is sometimes a 
general or localized cyanosis. A peculiar form of this cyanosis has 
been described by Finkelstein — the so-called angiospastic cyanosis — 
in which a central pallor and peripheral lividity are present in the 
patches. The cyanosis may be limited to the hands and feet. 

Eruptions of a pemphigoid character are sometimes seen in cases 
of sepsis of the newborn infant. The vesicles may be the seat of 
suppuration, or there may be ulcers and intertrigo varying from 
superficial erosions to extensive areas of gangrene. The skin may 
be pale or icteric in hue. There may be erysipelatous patches, fur- 
uncles, and multiple abscesses. 

Mouth. — The mucous membrane of the mouth is dry and fissured, 
and the tongue dry and coated. The roof of the mouth may be the 
seat of ulcerations, superficial or deep, occurring at the median raphe, 
where we find normally Epstein's pearls, or laterally over the hamular 
processes of the palate bone (Bednar's aphthse). The mouth may 
be the seat of pseudomembranous deposit not due to the diphtheria 
bacillus (Epstein). In these cases of sepsis sprue may engraft itself 
on the mucous membrane of the mouth and extend to the pharynx, 
oesophagus and stomach. 

Vagina. — The vagina in female infants may be the seat of catar- 
rhal or pseudomembranous inflammation. 

Umbilicus.— 'Normally, pathogenic bacteria are found about the 
stump of the desiccating cord, but do no harm ; under favorable con- 
ditions of sepsis, however, these bacteria may increase in numbers 
and virulence and become a source of great danger. In septic condi- 
tions the cord does not fall off promptly. The tissues about the 
umbilicus are inflamed and the seat of phlegmon and suppuration. 
Pus may burrow downward toward the bladder along the course of 
the -foetal structures. The bloodvessels of the cord may be the seat 
of inflammation, as will be shown later. In some forms of sepsis 
in which the infectious material may have gained entrance through 
the umbilicus, the latter may show absolutely no change from the 
normal. 

Bones and Joints. — There may be swelling in the muscles about 
the joints, as in forms of intramuscular abscess, or the "joint itself 
may be the seat of septic suppuration or so-called osteomyelitis ( Plate 
Y 1 1.). The shaft of flu 1 bone or the epiphysis only may be involved. 
One or many joints may be the seat of suppuration. 

Nervous System. — Functional symptoms, such as apathy, restless- 
ness, or convulsions, may be present, or there may be localized facial 
paralysis or paralysis of the extremities, traceable to meningitis or 
encephalitis. Hemorrhages in forms of sepsis may give rise 10 
paresis simulating the traumatic palsies oi' the newborn. 



204 DISEASES OF THE NEWBORN. 

Respiratory Tract. — The respiratory tract may present catarrhal 
or pseudomembranous inflammation of the nose, tonsils, larynx, or 
trachea. The bronchitis and pneumonia, especially in the septic 
forms of diarrhoea, may be of obscure nature and run an insidious 
course. 

The bronchopneumonia which accompanies sepsis of the newborn 
is septic in its nature, with but little febrile reaction and dyspnoea. 
Pleurisy and abscess of the lung may occur, but are frequently only 
discovered at the autopsy table. 

Circulatory System.- — The heart may be the seat of septic endo- 
pericarditis. This form of pericarditis is rarely diagnosed. 

Stomach and Intestines. — The intestinal tract may be the seat of 
a septic diarrhoea. There may be vomiting with severe gastro- 
intestinal symptoms, not infrequently with blood in the vomited 
matter as a manifestation of toxaemia. In the cases of septic diar- 
rhoea described by Fischl and Czerny there was complicating broncho- 
pneumonia of a severe type. 

Liver. — The liver may be the seat of enlargement in cases of 
extended duration, but the spleen is rarely so. 

Urine. — The urine may contain albumin and blood, not infre- 
quently leucocytes and casts, indicating a septic nephritis. 

Body-weight. — The body-weight diminishes markedly and rapidly. 

Temperature. — The temperature is not characteristic. In the 
severest forms of sepsis it may be normal or subnormal; in other 
cases there may be a rise of a degree or more. I have seen this in 
milder cases. A new complication may be ushered in with a rise 
of temperature, as often happens with older infants and children, but 
this is not necessarily so. 

Hemorrhages in the Eye. — In some cases examination of the 
fundus oculi shows the presence of hemorrhages. 

Morbid Anatomy. — The changes in the skin have been described. 
Those of the umbilicus will be found under the section of Umbilical 
Infection. The appearances in the mouth, nose, and throat have 
been described, as well as those of the lungs. The alterations in the 
gastroenteric tract are detailed in the chapter on Diseases of the 
Gastroenteric Tract. 

The liver and kidneys are the seat of parenchymatous or diffuse 
suppurative changes. The peritoneum is ordinarily intact, although 
formerly authors believed it to be frequently involved. The peri- 
cardium, endocardium, and myocardium may be the seat of slight 
or marked changes. Blood cultures may reveal the infecting bacteria. 

Diagnosis. — The origin of some cases of sepsis of the newborn 
infant is so obscure that not only is a diagnosis made with difficulty, 
but it is not always possible to determine the point of entrance of 



SEPTIC INFECTION OF THE NEWBORN INFANT. 205 

the infectious agent. In cryptogenetic cases no lesion may be visible. 
If an infant cries when it is diapered or washed in the hath, the 
joints should be examined for suppuration. A pseudomembranous 
deposit or an ulceration in the mouth is a sign of traumatism with 
infection. A diarrhoea in the newborn infant is of serious moment. 
The umbilicus, if swollen or red, should receive due consideration. 
Lumbar puncture has been proposed for the examination of the cere- 
brospinal fluid for micro-organisms, but this is hardly justifiable 
unless a meningitis be present. It has been suggested that the blood 
should be examined for micro-organisms by means of culture. In 
several of my cases in which this was attempted it was impossible to 
obtain the requisite amount of blood sufficient for a culture, the 
vessels being quite small at this age, and it being deemed inadvisable 
to enter an artery or a very large vein in order to obtain the requisite 
amount of blood. 

Puncture of the spleen for the detection of micro-organisms has 
been advised. Such a procedure may or may not be advisable, 
according to the indications in the case. 

Course and Prognosis. — Some forms of acute sepsis prove fatal in 
a few hours. Others, and they are the most common, last from a 
few days to a week. Others give no symptoms and result in sudden 
death of the infant. Finally, the subacute cases, which are compli- 
cated with progressive emaciation, diarrhoea, and pneumonia, extend 
over two or more weeks. Septic osteomyelitis and chronic omphalitis 
are especially protracted. The prognosis in these cases is always 
grave. Mild forms of intestinal sepsis, after pursuing a short course 
with fluctuating temperature, may recover completely. 

In subacute cases the danger of complications is ever present. 
Even if bacteria are found to be present in the blood, a recovery is 
not always impossible. 

Treatment. — There is no specific treatment for sepsis in the new- 
born infant. Prophylaxis is of the utmost importance. The hands 
of the accoucheur must be as clean in handling the newborn infant 
as in the treatment of the mother. The cord is tied with precautions 
described elsewhere. The mouth is not washed. As Epstein has 
pointed out, Bednar's aphthae and pseudomembranous inflammations 
are thus avoided. The nasal passages are not inspected more than 
is absolutely necessary. The bath-water should be clean and not 
below 38° 6. (100° F.). The food should receive attention. The 
infant should not nurse a fissured or an inflamed breast. The breast 
nipple should be cleansed before and after nursing, as statod in the 
section on Hygiene. The room in which the child sloops should be 
ventilated. Contact with the secretion of the mother (lochia) should 
ho avoided. 



206 DISEASES OF THE NEWBORN. 

Therapeutic measures will be directed toward the indication in 
each case. If a pneumonia or gastroenteritis be present, this com- 
plication is treated on the same lines as a primary infection of a 
similar nature. Osteomyelitis resulting in an accumulation of pus 
in the joints will receive surgical treatment. Cases complicated by 
meningitis also will receive the treatment indicated under the section 
on Meningitis as a Primary Infection. If the indications exist, such 
as pressure effects, a lumbar puncture may be performed. Abscesses 
are opened and erysipelatous and purulent skin lesions treated accord- 
ing to surgical procedure in each case. 

The strength should be supported, and for this purpose alcohol 
may be used with small doses of strychnine. The antistreptococcic 
sera are of doubtful efficacy. The administration of alkalies, such as 
the salicylate, benzoates, and carbonate of sodium, has been strongly 
advocated. High saline enemata are of value. Subcutaneous and 
intravenous saline injections have not proved successful. 

DISEASES OF THE UMBILICUS. 

Diseases of the umbilicus are classified as those which are purely 
local, such as blenorrhoea, phlegmon, gangrene, and erysipelas; those 
which begin as a local lesion and result in a general infection, such 
as arteritis and phlebitis umbilicalis, hemorrhage from the umbilicus ; 
and, finally, those which may be classified as anatomical deficiencies, 
the hernise umbilicales. 

Omphalitis. — The umbilical cord dries up and drops off in five 
days, leaving a granulating stump. In the case of weakly infants 
the cord may not fall off until much later. The stump may become 
inflamed and pus may form. This, in the majority of cases, is due 
to infection. 

Infection of the. site of the ligature of the umbilical cord may 
easily occur in the newborn, first, because bacteria are normally 
present, or may be conveyed to the site not only at the time of liga- 
tion of the cord, but after the stump has separated and the cord 
healed. Infection usually takes place at the time of ligation or 
before the cord separates from the stump. The appearance of the 
stump in omphalitis varies. In some cases the inflammation is 
slight, but in others the tissues are red, infiltrated, and coated with 
necrotic masses resembling pseudomembrane. Numerous small 
abscesses may be present. The great danger is that the process may 
involve the umbilical vessels. If the inflammation remains local, 
recovery is the rule. If the vessels become involved, sepsis may result. 

Treatment. — Proper ligation and care in dressing the cord will in 
most cases prevent subsequent infection. Cleanliness is of the first 



DISEASES OF THE UMBILICUS. 207 

importance. The hands, instruments, and the tape used for ligation 
should be scrupulously clean. The care of the stump of the umbilical 
cord has been a matter of much discussion. The ideal method of 
dressing the stump has not as yet been found. Some prefer not to 
bathe the child until after the stump has separated, in order to 
facilitate the mummification of the cord; others insist that if the 
dressing, hands, and water are clean, no danger results from the 
bath, and a daily dressing of the cord is not improper. This will 
be taken up elsewhere. If the cord is dressed daily, it should be 
dusted with some bland powder, such as dermatol, orthoform, or 
xeroform, even after the stump has separated and until the wound 
is completely healed, for the site of the umbilical cord is susceptible 
of infection even after the healing has taken place. The best dressing 
for the cord is sterilized absorbent gauze several layers thick, and 
perforated in the centre. The cord is passed through this perfora- 
tion and enclosed in the gauze. This dressing is renewed daily. If 
a suppurating surface appears, it should be treated on general sur- 
gical principles. As a rule, ointments should be avoided. The 
ordinary sterilized wet-dressing is sufficient. 

Umbilical Fungus (Granuloma). — In some cases the stump does 
not heal after the cord has separated, and a granulating surface 
which presents a fungoid appearance remains. The granulating 
mass may become as large as a bean and be pedunculated. There is 
secretion of pus. The affection is a benign one, and should not be 
confounded with the so-called enteratomata, which are rare. The 
latter are composed of smooth muscular fibre and tubular glands. 
These umbilical tumors have been described by Kolaczek, who believes 
that they are formed by the prolapsus of a persistent omphalomesen- 
teric duct. Yon Heukelom asserts that they are intestinal protru- 
sions through true diverticula of Meckel. Adenoid tumors of the 
umbilicus have been described by Lannelongue and Fremont. Hiit- 
tenbrenner has reported a polypoid tumor of the umbilicus, which he 
believed to be the remains of the allantois. 

Treatment. — If small and flat, the granulations are touched daily 
with silver nitrate stick and a dry dressing is applied ; or the granula- 
tions may be carefully scraped off and the stump dressed with steri- 
lized gauze after bleeding has ceased. If the growth is large and 
pedunculated, it should be ligated at its base with silk or catgut and 
a sterile gauze dressing applied. In a day or two the mass separates 
and healing takes place. 

Blennorrhoea of the Umbilicus.- — Blennorrhoea of the umbilicus 
is a condition in which there is considerable suppuration and secre- 
tion of pus after the slump of the umbilical cord has separated. 
The area of skin around Ihe umbilicus is red and excoriated. Under 
proper treatment this condition is curable. 



208 DISEASES OF THE NEWBORN. 

Phlegmon of the Umbilicus. — This is an inflammatory reaction 
of the umbilical wound due to some local infection. There is an 
omphalitis umbilicalis. The region of the umbilical wound is red, 
inflamed, and infiltrated, as is also the neighboring skin. There is 
pain. The condition may retrograde or the skin may break down 
and ulcerate, or abscesses may cause infection of the peritoneum. In 
the latter case the disease is invariably fatal. 

Ulcer of the Umbilicus. — The umbilical wound is here replaced 
by an ulcer of an irregular shape ; the neighboring skin is red and 
swollen, and there is a discharge of discolored pus. There is pain, 
uneasiness, and fever, or there may be no temperature. In some 
cases ulcers may exist with a pseudomembranous deposit. The dis- 
ease, however, has nothing in common with true diphtheria, but is 
due to wound infection of a streptococcic nature. The umbilical 
wound may become infected with diphtheria. In such a case the 
diphtheria bacilli will be found in the discharge and in the mem- 
brane on the wound. 

Gangrene of the Umbilicus. — This is a very serious condition, 
and occurs in weak infants amid unhygienic surroundings. The 
disease may develop in from six to thirty days after birth ; the wound 
becomes bluish or greenish red, discolored, or is converted into a dis- 
colored, greenish, bloody mass secreting ichorous pus. The gan- 
grenous process may involve the skin, and usually spreads into the 
depths of the abdominal wall, involving the urachus, the umbilical 
vessels, and finally the peritoneum. The prostration is great, and 
there may be little or no temperature; or the temperature may even 
be subnormal. Under these conditions there results a general sepsis, 
and the infant dies of toxaemia or complicating peritonitis. In some 
cases the gangrenous process begins in the subcutaneous tissues, 
spreads thence to the peritoneum, the overlying skin remaining toler- 
ably intact. This latter form of necrosis is only discovered and 
verified postmortem. 

Treatment. — The treatment of blennorrhoea of the umbilicus con- 
sists in applying some dry dressing with a dusting powder, such as 
dermatol. By applying this powder daily the condition is generally 
controlled. 

Phlegmon of the umbilicus is treated in the same manner as an 
ordinary phlegmon, by means of any convenient wet dressing. Liquor 
Burrowii or Thiersch's solution forms a very convenient dressing. 

Ulcer of the umbilicus is treated by means of wet dressing, or 
by the application of one part of balsam of Peru to four parts of 
castor oil, applied on gauze. The balsam-and-oil dressing is certainly 
very agreeable, and successful in many cases. 

Gangrene of the umbilicus is treated on surgical principles in the 
same manner as gangrene in other parts of the body. 



DISEASES OF THE UMBILICUS. 209 

Erysipelas of the Umbilicus. — This affection may involve the 
umbilicus and spread thence to the surrounding skin. It may, how- 
ever, remain local; but, as a rule, it spreads, involves; most of the 
surface of the abdomen, and in many cases ends in gangrene. If 
erysipelas remains localized, recovery may result ; if it spreads, how- 
ever, it is generally fatal. 

Infection of the Umbilical Vessels (Arteritis UwMlicalis). — 
Etiology. — This is an infection which may take place before or after 
the separation of the umbilical stump, and may occur by way of the 
bloodvessels or the perivascular connective tissue of the cord. 

In this affection the perivascular connective tissue of the cord 
may first become infiltrated with serum and be oedematous; later, the 
various coats of the arteries are affected. Thrombosis results, with 
disintegration of the thrombi. The lymph-vessels in the connective 
tissue of the cord carry the infectious material to the various parts 
of the body. 

It must not be forgotten that the normal stump of the cord con- 
tains bacteria; to be sure, of the non-virulent type or of reduced 
virulence. These cause no trouble. Given, however, uncleanliness, 
either in the dressings or otherwise, these bacteria combined with 
others may give rise to serious infection. The lochia, though not 
frequently, may be a source of infection. This infrequency is due 
to our means of asepsis, and to the protection which our present 
methods afford against epidemics of umbilical infection. 

Umbilical arteritis is a wound infection. It is most frequently 
seen in institutions, and is the result of implantation of septic matter 
on the umbilical wound by the hands or instruments, or through the 
bath-water or unclean dressings. Cases have occurred coincident 
with the presence of blennorrhoea. 

Morbid Anatomy. — There may be simple ulceration with discolor- 
ation of the umbilicus and purulent material in the lumen of the 
artery, with infiltration of perivascular tissue. The vessels running 
from the umbilicus appear as thickened discolored cords. The peri- 
vascular tissue is infiltrated. The process may begin about a centi- 
metre behind the umbilicus and extend downward toward the bladder. 
The umbilical stump may be normal in appearance or inflamed. The 
lumen of the arteries contain thrombi. The vessels may be dilated 
and contain disintegrated purulent masses. There may be lobar or 
lobular pneumonia, with pleurisy and hemorrhagic infarct ion of the 
lung. Parenchymatous inflammation o( the liver, kidney, and spleen 
and suppuration of one or several joints (see Osteomyelitis) may be 
observed. Peritonitis may be a complication. 

The bacteria found in most o( those cases have been streptococci 
ov staphylococci. 

14 



210 DISEASES OF THE NEWBORN. 

There may be metastatic abscesses in the various organs; the 
tissue of the heart may be the seat of parenchymatous degeneration; 
the epi- and pericardium may be the seats of ecchymoses and hemor- 
rhages, as also the pleura. There may be suppuration in the cavity 
of the pleura. 

Organs apparently normal in gross appearance may be the seat 
of parenchymatous degeneration. 

Symptoms.- — The symptoms of arteritis umbilicalis are often in- 
definite and give no clue to the cause of the illness. The infants 
gradually emaciate and succumb, the fatal issue supervening quite 
suddenly. The umbilicus may in these cases have been long healed 
and show no evidence of disease; in other cases it is inflamed. There 
is a sinus leading downward and backward toward the bladder, and 
from this pus exudes. A tense cord-like structure, the inflamed 
umbilical vessels, is felt beneath the abdominal wall. Sometimes the 
first intimation of serious disease is seen in the joints. The mother 
may tell the physician that the infant cries when it is bathed or 
dressed. In these cases the knee, ankle, or hip may be swollen, tense, 
and the seat of exudate. A septic osteomyelitis of the epiphyses of 
the joint is present, resulting in a suppurative arthritis. As a rule, 
more than one joint is involved. In other cases the symptoms are 
indefinite : there is a slight febrile movement. The skin has a slightly 
gray or icteric hue and may be the seat of erythema or hemorrhages, 
as mentioned under the heading of Sepsis. There may be a violent 
gastroenteritis or rapidly fatal pneumonia, or the lung symptoms may 
be equivocal and not very marked. In other words, there is a sepsis 
with the symptom-complex of a pneumonia or gastroenteric dis- 
turbance. 

Hennig's symptom, which consists of a so-called depressed triangle 
reaching from the umbilicus to the pubis, bounded by red lines indi- 
cating the inflamed arteries, accompanied by oedema of the wall of 
the abdomen, is not always present or to be depended upon. 

Course.- — The cases may be classed as acute, resembling sepsis 
and running a very rapidly fatal course, simulating a diarrhoea or 
pneumonia. Other cases may recover; these are the mild infections. 
The uncommon cases are those which run a chronic or subacute course 
with metastatic abscesses throughout the body. 

Prognosis. — These cases are generally fatal. A few of the mild 
cases recover. In these, however, it is a question as to whether the 
vessels have been involved or whether there was a true infection of 
a septic nature. The prognosis is especially unfavorable in prema- 
ture infants. 

Phlebitis Umbilicalis. — In this affection the veins which pass 
from the umbilicus to the liver are the seat of an inflammatory 



DISEASES OF TEE UMBILICUS. 211 

process similar to that affecting the arteries in the affection just 
described. There is a true phlebitis, with pus in the lumen of the 
veins, in some cases extending into the liver. The branches of the 
portal vein are involved. The picture presented is that of metastatic 
abscesses, as contradistinguished from the parenchymatous degenera- 
tions which make up the picture of arteritis umbilicalis. The umbil- 
ical vein is dilated and filled with pus ; the intima is swollen, inflamed, 
or eroded; the suppuration extends to the liver, which, with the 
spleen and kidneys, may be the seat of metastatic abscesses. There 
is peritonitis of the diffuse variety. Pleuritis, meningitis, and brain 
abscess may result. There may be abscess in the skin and also in 
the joints, the whole picture being that of pyaemia. In some cases 
the symptoms resemble those of peritonitis complicated with icterus ; 
the respirations are shallow, the abdomen tense, and the thighs are 
flexed on the abdomen. 

Treatment. — It is hardly necessary to say that prophylaxis is in 
all septic affections the mainstay of the physician. Once inaugu- 
rated, infective processes in newborn infants are progressive. In 
cases of the umbilical type I have advised laying open the structures 
passing from the umbilicus to the bladder, curetting the sinus thus 
formed, and inducing healing from the bottom. Recovery has fol- 
lowed in a few exceptional cases. The operation should be per- 
formed before general infection has occurred. Yan Arsdale operated 
on one of these cases for me and obtained an apparent recovery — 
that is to say, the sinus leading from the umbilicus healed and there 
were no symptoms for weeks after the operation. 

In some recorded cases the liver has been incised for abscesses. 
One case occurred in an infant three months of age, the subject of 
umbilical phlebitis. The results obtained with antistreptococcic sera 
have not been encouraging. 

Hemorrhage from the Umbilicus ( Omphalorrhagia) . — Hemor- 
rhage from the umbilicus may occur (a) from the vessels of the umbil- 
ical cord or (b) from the umbilical wound itself (parenchymatous). 

Hemorrhage from the vessels of the cord may occur if the ligature 
has not been properly applied ; but faulty ligation alone will not 
account for the hemorrhage in all cases. Range states that if the 
cord is cut ten or fifteen minutes after a healthy infant has cried 
lustily there will be little hemorrhage— certainly not one threatening 
life. The diminution of arterial pressure in the bloodvessels at 
this point, due to the establishment oi' the pulmonic circulation and 
the natural contractility of the vessels, prevents hemorrhage. The 
fact that infants among savage peoples and the young of lower animals 
do not bleed to death, although the covA is not ligated, bu1 simply 
divided, is thus explained. If an infant, therefore, bleeds after 



212 DISEASES OF THE NEWBORN. 

ligation of the cord, the reason must be sought in some physiological 
or anatomical defect of the bloodvessels. We possess no data which 
would explain the absence of normal arterial contraction in the ves- 
sels of the cord. Inasmuch as this condition may be present during 
the first days after birth, great care should be taken that the ligature 
is properly applied. Caution should especially be exercised with pre- 
mature infants, in whom the bloodvessels are in an embryonic state. 

After the separation of the umbilical stump a few drops of blood 
may be seen on the wound from time to time. This is of no moment. 
The wound should be dressed with a salicylic powder and amylum 
(1:5), and covered with a dry dressing. 

Idiopathic Hemorrhage from the Umbilicus (True Omphalor- 
rhagia). — Occurrence.- — Winckel, quoted by Runge, has seen only 1 
case in 5000 births of true idiopathic hemorrhage from the umbil- 
icus. Males are more frequently attacked than females. I have seen 
a few cases of this affection. 

Etiology. — According to Grandidier, infants apparently healthy 
and strong are for the most part affected. This form of hemorrhage 
occurs also in infants suffering from congenital syphilis, septic infec- 
tions, or the acute fatty degeneration of the newborn. In some forms 
of congenital syphilis there may be hemorrhages into the skin, stomach, 
intestine, and internal organs. In these cases it is not surprising 
that hemorrhage should also occur from the umbilicus. Icterus, due 
to syphilitic affections of the liver and lung, may be present. 

In 51 cases of hemorrhage from the umbilicus, Epstein found 
pronounced septicaemia in 24. The affection is especially prevalent 
under unhygienic conditions and in foundling asylums. Klebs, Ep- 
pinger, Cohnheim, and Weigert have described cases of hemorrhage 
in which micro-organisms of various kinds were found in the blood 
and in the hemorrhagic areas. Bacterial colonies were found in the 
arterial thrombi and in the lungs and kidneys. 

The occurrence of hemorrhage from the umbilicus in Buhl's dis- 
ease is elsewhere described. 

Symptoms. — About the fifth day after birth, immediately follow- 
ing separation of the umbilical stump, blood is seen to ooze from the 
umbilicus. It does not appear to issue from any particular vessel, 
but oozes from the whole umbilical wound, as from a sponge. The 
flow may be slight at first and then profuse, or may be profuse from 
the outset. Pressure upon the wound may cause the hemorrhage to 
cease, but the flow begins when pressure is withdrawn. In some 
cases the infants have enjoyed excellent health previous to the hemor- 
rhage. In others there may have been a slight icterus or diarrhoea. 
However this may be, after bleeding commences cyanosis and icterus 
of the general surface appear, giving the skin a peculiar bronzed 



DISEASES OF THE UMBILICUS. 213 

appearance. There are hemorrhages from the stomach and gut. 
Ecchymoses appear in the vicinity of the umbilicus and on other parts 
of the trunk. (Edema of the ankle-joints and wrists supervenes. 
The hemorrhage from the "umbilicus is the most characteristic symp- 
tom, and cannot be controlled by any means. The blood coagulate- 
very slowly. 

Duration.' — The disease lasts from a few hours to two weeks. 
Grandidier's statistics give a mortality of 83 per cent. Death ensues 
in collapse, with convulsions. 

Treatment. — Treatment is directed to controlling the hemorrhage 
by pressure or by transfixing the umbilical wound. Erom a study of 
the pathogeny of this affection, it is evident that no form of local 
treatment can be successful. 

Umbilical Herniae. — In newly born infants we distinguish two 
varieties of hernia at the umbilicus. 

The first form is of serious character. It is really a hernia of 
the umbilical cord (hernia funiculi umbilicalis). The condition is 
due to an arrest of development, as a result of which there is a true 
defect in the abdominal wall at the situation of the umbilicus. The 
gut prolapses and is covered by the amnion of the cord and Wharton's 
jelly, beneath which is the peritoneum. The latter is immediately 
over the gut. Many of the infants thus affected are premature. In 
others deformities are present. The hernia is a round or oval tumor 
of the size of a walnut or an orange, located in the region of the 
umbilicus, and is continuous with the cord. The sac of the hernia 
is formed by the peritoneum and amnion. The abdominal walls 
form the border of the sac. Gut, liver, spleen, kidney, or pancreas 
may be found in the sac. 

If treatment is not instituted at the time of separation of the 
cord, and the hernia is large, ulceration, gangrene, or septic peri- 
tonitis in the sac contents may result. 

The second and most common form of hernia in this region is 
due to a weakness at the point of insertion of the cord. The hernia 
becomes apparent a few weeks after birth, when the cord has eom- 
pletly cicatrized. It is then noticed that when the infant cries there 
is a protusion at this point. The protrusion may be small or large, 
and is covered by the thin cicatrized skin. The hernia may be 
central or at one side, or a little above or below the centre of the 
umbilical ring. 

Treatment. — The treatment of I he first form is purely surgical, 
and consists in splitting open the sac and sewing the abdominal 
parietes in apposition. The treatment of the second form is simple. 
As a prophylactic measure a small pad should he placed tut the 
abdomen, underneath the binder, and should he worn for some time 



214 



DISEASES OF THE NEWBORN. 



after the stump is healed, in order that there may be no protrusion 
of the wall and gut during crying spells. If the hernia has taken 
place, a firm pad, made by enclosing a piece of thick cardboard, Gne 
and a half inches in diameter, in a piece of linen, should be applied, 
and supported by rubber plaster. Another method is to reduce the 
hernia, fold it inward by means of the apposing abdominal walls, and 
secure the walls thus brought together with plaster. The plaster 
should be renewed every three days lest ulceration of the skin result. 
As soon as the muscles of the abdomen gain strength and the infant 
is able to stand, the opening at the umbilicus closes and the hernia 
remains reduced. 

PERITONITIS OF THE NEWBORN. 

Occurrence. — This affection may occur from the first to the seventh 
day after birth, and sets in, as a rule, with vomiting, pain, as evi- 
denced by crying; diarrhoea, tympanitis, disappearance of the liver 
dulness, dulness in flanks, showing the presence of fluid in the abdom- 
inal cavity. Peritoneal fluid may collect in the pelvis and appear 
in the scrotum, simulating hydrocele. In such a case the right side 
of the scrotum is mostly affected, and there is accompanying oedema. 
The temperature may be as high as 40° C. (104° F.). There are 
restlessness, emaciation, facies, and death supervenes in from four 
to five days. Infection is not always limited to the peritoneum: 
there may be blennorrhoea, phlegmon, erysipelas, hemorrhages, or 
gangrene of the umbilicus, and with these we may have arteritis, 
pleurisy, and visceral abscesses. Peritonitis of the newborn may 
originate at the umbilicus, which is a port of entry for bacteria. 

Prognosis. — The prognosis of these cases is grave; most of them 
result fatally. 



TETANUS OF THE NEWBORN INFANT. 

(Trismus Neonatorum.) 

Tetanus of the newborn is an acute infectious disease or intoxi- 
cation, strictly speaking, characterized by trismus and tonic muscular 
spasms, rarely convulsions. 

Etiology. — Tetanus of the newborn infant is in the majority of 
cases due to infection of the umbilical wound by the tetanus bacillus. 
The bacillus is conveyed to the wound by means of unclean hands, 
bandages, or filth of any kind. As a result of the growth of the 
bacillus ptomaines are formed, enter the circulation, and are widely 
distributed throughout the body. Infection may occur at the time 
of the ligation of the cord or during the separation of the stump. 



TETANUS OF TEE NEWBORN INFANT. 215 

Iii 8 per cent, of the cases the disease manifests itself immediately 
after birth (Hartigan). 

Hartigan's assertion that in most cases symptoms appear from 
the first to the fifth day after the separation of the stump of the 
cord is incorrect. As a rule, the onset is from the fifth to the twelfth 
day after birth (Eunge). It is rare after the third week. The incu- 
bation period in the human subject varies from one to sixty days. 
In animals which have been the subject of experiment the period of 
incubation has been but a few hours. Subdural injections in animals 
have given the shortest incubation period. 

Tetanus is common in districts in which uncleanliness in the 
methods of treating the umbilical cord prevails. It is endemic in the 
Faroe Islands, and is common in the Hebrides, Cuba, and Jamaica. 
Negroes, especially, are prone to the malady, on account of their lack 
of cleanliness in treating the cord. Tetanus of the newborn infant 
has been demonstrated by Beumer and Peiper to be identical with 
tetanus in the adult. 

Morbid Anatomy. — Beck has described two cases of tetanus with 
swelling of the motor ganglion-cells, and degeneration of the periph- 
eral portion of the cells with atrophy. There are also changes in 
the chromatin of the cell. Congestion and hemorrhages in the brain 
and cord, serous exudates in the cord, and congestion of the internal 
organs, due to convulsions, are present. 

Symptoms.— There is a premonitory period of restlessness. The 
infants awake abruptly from sleep. They nurse badly, let go of the 
nipple suddenly, and cry. The peculiarity of the disease in infants 
is the predominance of trismus, with which the attack begins. The 
lower jaw becomes rigid and fixed at a distance of a few lines from 
the upper jaw. It is impossible to introduce the nipple between the 
teeth. At first there is a tremulous contraction of the muscles of 
the lower jaw. It is then noticed that the infant is unable to open 
the jaw, and on slight irritation, either with the fingers or with the 
breast nipples during nursing, the lips become puckered into the 
position of playing the flute, and the jaw is contracted and fixed. 

The muscles of deglutition become affected, so that swallowing 
is impossible, and all fluid introduced is returned or rejected. The 
forehead is wrinkled, and the palpebral fissure diminished. The 
condition of rigid spasm spreads to the other muscles of the body. 
such as those of the neck, back, and extremities, and there is opis- 
thotonos. At intervals this spasm relaxes. At the outset, during 
the intervals between the attacks of rigidity, the body is lax; during 
such intervals the unfortunates may obtain some rest and take nour- 
ishment. These intervals become shorter and shorter, until finally 
the body is in a state of constant rigidity, resting on the heels ami 



216 DISEASES OF THE NEWBOBN. 

the back of the head. The muscular spasm is a tonic one, called 
forth by the least irritation, or by sound or a moving body in the 
room, or even by a draft of air. Dyspnoea with resultant cyanosis 
is present when the muscles of respiration become affected. Deglu- 
tition is impossible. There is no cry, on account of spasm of the 
laryngeal muscles. The temperature may reach 41° C. (106° F.). 
In protracted cases it may be normal. The pulse is accelerated. 
The urine and faeces are passed involuntarily. There is albumin in 
the urine. The respirations are superficial. The heart action is 
increased; the pulse may be 200. During a contracture the skin is 
dark red and cyanotic. Icterus may be present. The face is fixed 
in expression and cedematous. 

Duration. — The disease lasts from a few days to three weeks. 
Death may ensue in from one to six days from asphyxia or exhaus- 
tion. In rare cases the attacks become less and less frequent, and 
finally cease. Fracture of the bones and rupture of the muscles are 
among the complications. 

Diagnosis. — The diagnosis offers no difficulties. The sudden onset 
and rigid contraction of the muscles of mastication and deglutition, 
the intensification of the contractures by the least irritation, the opis- 
thotonos with intervals of relaxation and contraction, the tempera- 
ture — all tend to aid in the diagnosis. The only question which can 
arise is that relative to the differentiation of tetanus from contractures 
with paralysis due to traumatism after birth. In the latter case, 
however, there will be corresponding pareses, such as are seen in 
the face. 

Again, tetanus may be confounded with cerebrospinal meningitis 
in the newborn, due to infection with staphylococci, streptococci, or 
meningococci. In meningitis there is no trismus or tetanic spasms, 
though there may be rigidity of the muscles of the neck and back. 
In doubtful cases lumbar puncture will reveal micro-organisms of 
meningitis in the cerebrospinal fluid. 

Prognosis. — The prognosis is grave. Baginsky lost all of his cases 
in newborn infants, while Escherich, Soltman, and Monti report 
recoveries. Cases which occur late, after separation of the cord, 
give a better prognosis (Papiewski). Patients die of exhaustion, 
as a result of sleeplessness, lack of food, and general strain on the 
nervous system. 

Treatment. — Prophylaxis is of the utmost importance in this as 
in other diseases of the newborn infant. Cleanliness in handling the 
cord is of the first importance. Escherich cauterizes the stump of 
the cord, to destroy any bacilli of tetanus which may be present. 
On the appearance of trismus, the treatment is first directed to the 
relief of the tonic spasms. Chlorate hydrate in 1-grain (0.06) doses 



ICTERUS IN THE NEWBORN INFANT. 2] t 

every few hours, by mouth, or by the rectum, is a very useful drug. 
Calabar bean in the form of the extract is recommended by Monti, 
who gives %2o grain (0.0005) subcutaneously, repeated until the 
desired effect is obtained. Cannabis indica, \ grain (0.03) every 
two hours, is also given internally. Curare has been used but little 
with the newborn infant. Of the other remedies, bromide of potas- 
sium and trionol have little effect. 

Aside from the treatment of tetanus in the newborn by means of 
drugs, the treatment by means of tetanus antitoxin should be resorted 
to in every case, in spite of the fact that failures have been recorded 
by Heubner, Ley den, and Blumenthal. We should inject antitoxin 
as soon as symptoms appear, inasmuch as favorable cases have been 
reported by Tizzone, Behring, Engelmann, Kohler, and others. The 
antitoxin is given by means of lumbar puncture. A puncture is 
made in the ordinary way in the lumbar region, as elsewhere de- 
scribed. Five cubic centimetres of cerebrospinal fluid is allowed to 
flow off. The Quincke funnel is then attached to the puncture-needle 
and 5 c.c. of antitoxin are introduced. Another method is to inject 
half of the serum by lumbar puncture and the other half sub- 
cutaneously. 

The use of the tetanus antitoxins has not given satisfactory results, 
probably owing to the fact that tetanus is a symptom of advanced 
toxsemia of the nervous system. In such a condition the action of 
any antitoxin would be exerted too late to give permanent benefit. 
These patients being unable to swallow must be fed per rectum until 
the acute symptoms have subsided and deglutition is possible. 

ICTERUS IN THE NEWBORN INFANT. 

The majority of newborn infants are icteric. Icterus in the 
otherwise normal newborn infant should be differentiated from that 
due to sepsis, syphilis of the liver, cirrhosis of the liver, stenosis of 
the common bile-duct, and yellow atrophy of the liver. Acute yellow 
atrophy of the liver in the mother during pregnancy may produce an 
icteric condition in the newborn infant. 

Icterus Neonatorum. — An opportunity is rarely afforded to in- 
spect postmortem the viscera of cases of icterus neonatorum, since 
recovery ensues in the majority of cases. In cases which have come 
to the autopsy table, all the internal organs, including the bones and 
cartilages, were icteric. The spleen and kidneys were but little 
affected, even in severe forms, by the general icteric discoloration. 
In rare cases the liven' was microscopically jaundiced. The intiina 
of ihe arteries, the fluids in the serous cavities, the pericardia] fluid, 
and the subcutaneous and intermuscular connective tissue have been 



218 DISEASES OF THE NEWBORN. 

found to contain "bile-pigment and biliary acids (Birch-Hirschfeld). 
The contents of the gut were normal. The kidneys contained uric 
acid infarctions. 

Etiology. — Icterus neonatorum is as frequent in institutions as 
in private practice. It is more common among boys (Kehrer). It 
is seen in premature weak infants, and in those whose birth has 
been attended by complications. The disease is now traced to both 
a hematogenous and a hepatogenous source. There are certain 
processes in the blood which also involve the functions of the liver. 
According to Hofmeier and Silbermann there is a disintegration of 
red blood-cells in the circulation. These disintegrated red blood- 
cells are converted by the liver cell into biliary pigment ; the solids 
of the bile are increased, as is also the gross quantity of bile (Min- 
kowski, ISTaunyn, Stadelmann). It is not known, however, how 
this increase of bile-pigment gains access to the circulation. One 
theory (Silbermann) is that with the processes described above cer- 
tain ferments are set free which cause circulatory disturbances in the 
liver. Stasis results in the bloodvessels, with consequent pressure 
on the biliary ducts. Resorption of bile thus follows. 

Symptoms. — Fully 80 per cent, of all newborn infants become 
jaundiced shortly after birth (Runge). The jaundice appears on the 
second or third day after birth. The icterus may be slight and 
involve only the face, breast, and back, or may be severe and extend 
over the whole trunk. In severe forms icterus of the conjunctiva? 
is present. In this feature icterus neonatorum differs from ordinary 
catarrhal icterus, in which icterus of the conjunctivae is the first 
symptom before the skin is perceptibly tinged. The conjunctivae are 
last to be tinged in the jaundice of the newborn. Infants suffering 
from icterus, though in an apparently normal condition, do not 
increase in weight as normal infants do, and may even lose ground. 
When they recover lost weight, they do so slowly. 

The urine is brownish at times and contains biliary pigment and 
acids (Cruse Hofmeier). 

Treatment. — Icterus neonatorum, if untreated, disappears in three 
or four days in mild cases ; severe cases are more protracted. Neither 
form needs special treatment. 

Icterus Gravis of the Newborn. — This is a form of icterus oc- 
curring in the newborn. It is characterized by its severity and the 
intensity of the icterus, accompanied as it is by hemolysis and pig- 
mentation of the mucous surface; it is generally fatal. It has been 
described by Benecke and Pfannestiel; it occurs in families: one 
author having seen nine cases in the same family. Autopsy shows 
affections of the serous cavities ; punctate hemorrhages in the internal 
organs; increase in size of the liver and spleen and general intense 



MELMNA NEONATORUM. 219 

icterus. In cases so far published, the parents gave no syphilitic 
history. The authors mentioned do not consider it identical with 
Buhl's or WinckeFs disease, or dependent on any septic infection, 
but rather classify it as a dyscrasia. 

HEMORRHAGES IN THE NEWBORN. 

Hemorrhages in the newborn are frequent as a result of infec- 
tion. These hemorrhages may accompany ordinary septic infection 
and form part of the symptomatology of sepsis ; or they may assume 
a characteristic symptom-complex, and, as such, make up a definite 
picture corresponding to what has been formerly described, and still 
retained in the text-books for the sake of lucidity, as melsena neona- 
torum, WinckeFs disease, and Buhl's disease. Hemorrhages in the 
newborn may occur from the nose, the mouth, the conjunctiva, the 
umbilical wound, the stomach, the intestines, the vagina, the skin, 
and into most of the internal organs. The causes of such hemor- 
rhages are either congenital haemophilia, or an underlying dyscrasia, 
such as syphilis, or septic infection. A congenital haemophilia is 
rare and plays but a minor role in the causation of hemorrhages in 
the newborn. Grandidier records only 12 of 575 cases of hemor- 
rhage caused by haemophilia. In syphilitic infants hemorrhages 
may occur from two to three days after birth, either underneath the 
skin, from fissures in the skin, from the stomach, the intestines, or 
the internal organs. Some contend that in these syphilitic infants, 
in addition possibly to some infection, there is a change in the 
arteries; others deny that such changes exist, and contend that the 
arterial changes described by Mracek are found in the normal infant 
(Fischl). Inasmuch as these syphilitic infants come into the world as 
weaklings, and are on this account susceptible to infection, it is more 
rational to suppose that if hemorrhages occur they are the result ol 
septic infection. Sepsis, therefore, is the main factor in the causa- 
tion of all hemorrhages in the newborn. The clinical symptoms oi 
these hemorrhages and accompanying constitutional disturbances will 
be described under the sections devoted to them. Some forms of 
hemorrhage have been considered in the sections which treat of sepsis 
of the newborn, diseases and infection of the umbilical wound, and 
structures. The remaining forms will now be described, and for the 
sake of lucidity the early nomenclature is still retained. 

MEL.ENA neonatorum. 

Etiology. — This is a disease of the newborn characterized by a 
discharge of blood from the rectum and bv vomiting oi' blood. It is 
a rare affection, occurring about once in L000 births (KKng, Genrich, 
Runge). The hemorrhages occur in two distinct conditions: 



220 DISEASES OF TEE NEWBORN. 

(a) As a symptom of a constitutional dyscrasia. This condition 
has been treated of under the headings of Hemorrhagic Congenital 
Syphilis, Sepsis, and the Acute Fatty Degeneration of the Newborn. 
Eunge has shown that not only may the diseases named cause melaena, 
but that any of the infectious diseases of the newborn may give rise 
to this condition. 

(b) The second condition in which melsena occurs is that in which, 
as Landau, in his monograph on this disease has shown, local lesions, 
such as erosions and ulcerations resembling ulcus ventriculi, exist in 
the stomach and gut of the newborn infant. Hecker, Spiegelberg, 
and others have also described these ulcers of the stomach which 
produce the symptoms of melsena. Landau attributes the ulcers to 
embolism resulting from a thrombus of the umbilical vein or the 
ductus Botalli. Embolism in any artery of the mucous membrane 
of the stomach gives rise to necrosis and erosion, with the opening 
up of some arterial branch. Ingenious as this theory is, it is not 
accepted unreservedly by all, although Landau has proved the pres- 
ence of emboli in the vicinity of stomach ulcerations. Another 
theory ascribes the ulcerations to hyperemia of the mucous membrane 
in asphyxia and traumatism. 

Melsena neonatorum can be caused not only by a coccal sepsis, but 
by a bacillary infection, as shown by Gartner, who found a bacillus 
in the faeces, and in the hemorrhages from the various organs and 
peritoneum. In other cases it is very probable other microorganisms 
will be found to have caused the sepsis. 

In addition there are cases in which no cause can be found to 
account for the symptoms. 

Morbid Anatomy. — Postmortem examination shows the gastro- 
enteric tract to be filled with dark hemorrhagic masses. The mucous 
membrane may be normal, the seat of erosions of greater or lesser 
extent, or there may be hemorrhagic areas scattered throughout the 
gut. These may be confined to the stomach or duodenum. There 
may be true ulcers of the stomach measuring |- to 2 cm. in diameter, 
resembling those seen in the adult (Winckel). In some cases the 
thrombosed or eroded vessel is found in the floor of the ulcer or in 
its vicinity. All the organs are anaemic, and if syphilis or some 
other general disease exists there are the changes found in these 
conditions. 

Symptoms. — From two to four days after birth it is noticed that 
the infant is somnolent or restless ; there may be hemorrhagic stools 
or vomiting of bloody masses, or both these symptoms may be present 
at the same time. The principal symptom, however, is the bloody 
stools. These are at first mingled with meconium, and later become 
frequent and profuse. The vomited matter consists of mucus 



ACUTE FATTY DEGENERATION OF TEE NEWBORN. 221 

streaked with blood, or masses of blood of brownish color. The 
amount of blood lost by the bowel within twenty-four hours may be 
quite great. Under these conditions death ensues within a period 
of from twelve to twenty-four hours, with all the symptoms of acute 
anaemia. In other cases there may be a cessation of the intestinal 
hemorrhage for from twenty-four to forty-eight hours, but recovery 
does not always take place, and sudden death from a severe hemor- 
rhage may occur at any time. 

Prognosis. — The prognosis is grave. Sixty per cent, of the infants 
affected die. The outlook is more serious in conditions of sepsis, 
syphilis, and acute fatty degeneration than in melsena due to ulcer of 
the stomach or duodenum. 

Diagnosis. — We must differentiate this disease, which is called 
true melsena, from the so-called spurious form, in which the infant 
simply passes blood swallowed with the food. This spurious form 
may occur if the breast nipple is fissured or if there is a fissure of 
the anus. In other cases blood from the nose or mouth of the infant 
may be swallowed. Hemorrhages of this kind may occur as part of 
a general septic infection. In many cases there may be, with other 
hemorrhages, icterus, cyanosis, oedema, pointing to some general dis- 
ease. Sensitiveness in the region of the stomach points to ulcera- 
tion of this organ. 

Treatment. — The hemorrhages should be controlled by the appli- 
cation of a cold coil to the epigastrium and the administration of cold 
drinks. Henoch recommends a drop of liquor ferri sesquichloridi 
every hour in barley-water. Ergotin is given in doses of \ to f 
grain internally or subcutaneously. Suprarenal extract has been 
administered in some cases which have recovered and may be tried. 
In a case coming under my care adrenalin was of no avail. Enemata 
are not advisable. The heart is stimulated with strychnine, digitalis, 
camphor, or ether. 

ACUTE FATTY DEGENERATION OF THE NEWBORN. 

(Buhl's Disease.) 

This disease, first described in 1S61 by Buhl, is an acute paren- 
chymatous fatty degeneration of the liver, kidney, or heart, combined 
with hemorrhages into the various organs, or from the umbilicus, 
intestines, or stomach. 

Etiology. — The disease occurs in the lower animals, especially in 
sheep. In the human subject it is a form of septic infection, although 
in Buhl's cases the vessels of the umbilicus had a normal appearance. 
Septic infection may occur without any appreciable changes about 
the umbilicus or elsewhere on the surf ace of the body (cryptogenetic). 






222 DISEASES OF THE NEWBORN. 

The disease is very rare ; many cases described as omphalitis and 
hemorrhage from the umbilicus probably belong to the category of 
Buhl's disease. 

Morbid Anatomy. — The body is icteric or cyanotic ; there is oedema 
of the surface, and not infrequently hemorrhagic areas in the skin. 
The umbilicus may be covered with blood, but the vessels and wound 
are otherwise normal. Hemorrhages or petechia? are found in most 
of the internal organs, especially the pleura, pericardium, medias- 
tinal tissue, muscles, and mucous membranes. The heart is the seat 
of fatty degeneration, as is also the liver, which is enlarged. The 
spleen is enlarged and soft. The kidneys are the seat of fatty paren- 
chymatous changes. The stomach and intestines are filled with blood. 
There are hemorrhages into the mucous membrane of the stomach and 
intestine. The intestinal villi are the seat of fatty degeneration. 

Symptoms. — The children are born partially asphyxiated. At- 
tempts to resuscitate them are not fully successful. Some die in 
asphyxia, others after a time have bloody diarrhoeal stools. At times 
there is vomiting of blood, and when the stump of the cord separates 
there is hemorrhage from the umbilicus. The bleeding from the 
umbilicus is parenchymatous, and may be so profuse as to cause death. 
The skin is at first cyanotic, then icteric in hue. Large hemorrhagic 
areas appear in the skin, conjunctiva?, and mucous membrane of the 
mouth, and bleeding may occur from the ear and nose. Icterus may 
become extreme. At times oedema of the surface appears. The 
temperature is not raised. Death ensues in collapse. The external 
hemorrhages and icterus are absent in some cases. 

Diagnosis. — In the newborn infant this symptom-complex is 
unique, and must be looked upon as a form of sepsis, either through 
the umbilicus or through some other avenue. In the newborn infant 
this disease may be confounded with death from asphyxia. In all 
cases of medico-legal import the organs should be examined for 
parenchymatous changes before an opinion is given. 

Prognosis. — The disease is fatal. 

Treatment. — The physician endeavors to bring the infant out of 
the state of asphyxia. It can be easily understood that he is helpless 
in the face of the parenchymatous hemorrhages and degenerations,, 
for which there is at present no remedy. 

WINCKEL'S DISEASE. 

(Epidemic Hemoglobinuria of the Newborn.) 

This disease, first described in the epidemic form by Winckel. is 
characterized by the sudden appearance of cyanosis and icterus with 
hsemofflobiimri a . 



WINCKEL'S DISEASE. £2,6 

Etiology.— The etiology of the affection is obscure. Epstein, 
Strelitz, and Baginsky consider the disease a form of septic infection. 
Winckel's cases were believed to be due to the use of infected drink- 
ing or bath, water. Birch-Hirschfeld and Strelitz found streptococci 
in the various organs and the blood. Kamen, in an epidemic of the 
disease, found the colon bacillus in the capillary bloodvessels and 
various organs. 

Morbid Anatomy. — Postmortem examination reveals no disease of 
the umbilicus or umbilical vessels. The kidneys are the seat of cor- 
tical hemorrhages. The spleen is large and hard, and filled with 
pigment. There are punctate hemorrhages in almost all the organs, 
especially in the pleura, pericardium, and endocardium. Hemor- 
rhages are present in the mucous membrane of the stomach and gut, 
and underneath the liver capsule. Peyer's patches, solitary follicles, 
and mesenteric glands are enlarged. The liver, heart, and various 
organs show fatty degeneration. There are bacterial foci in the 
liver and kidneys. The blood shows an increase in the leucocytes 
and in the free granules. 

Symptoms. — The symptoms in Winckel's cases appear on the 
fourth day after birth in apparently healthy and well-developed 
infants. The average duration is thirty-two hours. Some infants 
succumb in nine hours after the onset of symptoms. Restlessness 
and cyanosis are first noted. The latter is general, affecting the 
trunk and extremities. Icterus then develops, and becomes marked 
within twenty-four hours. The respiration and pulse are accel- 
erated; the temperature may be normal, 38° C. (100.5° P.) : the 
skin is cool. At times there are vomiting and diarrhoea. The urine 
is passed with tenesmus, brownish in color, and contains blood-cells, 
haemoglobin, renal epithelium, granular casts, micrococci, detritus. 
and ammonium urate. Convulsions close the scene. If the skin is 
cut, a brownish syrupy fluid exudes. 

Diagnosis. — Owing to the similarity of symptoms, Winckel's dis- 
ease may be confounded with Buhl's disease. The former pursues a 
very malignant course, and does not present the intestinal and stomach 
hemorrhages to the same extent as the latter. 

Runge and others are inclined to believe that all these hemor- 
rhagic affections are due to a common cause — septic infection. The 
hemoglobinuria is simply a marked hemorrhage into the kidney. 
Parenchymatous fatty degeneration o( the various organs is common 
to both affections. 

Prognosis. — The prognosis is fatal. 

Treatment.- —The Ireatnionl is that oi sepsis o( the newborn. 



224 DISEASES OF THE NEWBORN. 

SCLEREMA. 

{Sclerema Neonatorum; Scleredema Neonatorum; Sclerema Adiposum.) 

This peculiar and rare affection is apt to be confounded with 
ordinary oedema. There are two forms of this condition: one form 
called scleredema, or edematous scleredema of Soltman ; the second 
form is called sclerema adiposum, or fat sclerema. 

Scleredema (Soltman). — This affection is not so rare in institu- 
tions on the continent of Europe, although in this country it is 
uncommon. It is not as common a disease as fat-sclerema, which 
will be described later. It is a disease of the newborn, and occurs 
only in the first days of life. Some children, according to Dennis, 
Billard, and Demme, are born with the disease. In these cases the 
children are born cold, stiff, cannot move, the surface is swollen, 
edematous, tense, a great extent of surface being involved in most 
cases; and in some cases even an ascites is present. In some, how- 
ever, the feet are first swollen, then the whole body becomes involved 
later on. Most of the cases published have been fatal in from a few 
hours to a few days after birth. The form seen after birth occurs 
mostly in premature infants, or in the congenitally weak infant, one 
of twins or triplets, or in infants with a syphilitic history. The 
disease usually begins four days after birth, or may appear as late 
as the tenth day or in the third week. These children, as stated, are 
mostly underweight and congenitally weak. 

Etiology. — The etiology of scleredema, or acute edema, is still a 
matter of speculation. Weakness of the heart, a beginning nephritis, 
or an infection of some kind, deficiencies in circulation and respira- 
tion in premature infants, unhygienic surroundings — all have been 
advanced to explain this rare condition. In the secondary form, the 
so-called sclerema adiposum, there is to a certain extent a desiccation 
of the subcutaneous tissues. Sanger thinks that the excess of pal- 
matin and stearin in the subcutaneous fat of the newborn infant may 
account for the peculiar solidification, since the temperature is 
reduced, as it is in fat-sclerema. There are cases of fat-sclerema in 
which the temperature, as has been stated, is elevated. Such was 
Barker's case, and I have recently seen such a case, so that the theory 
of Sanger is scarcely adequate. The cases of fat-sclerema which I 
have seen have created in my mind the impression of an infectious 
condition ; though this etiology is denied by most investigators. 
Barker found streptococci in the internal fluids after death. 

Symptoms. — There are no prodromata, except possibly an uneasi- 
ness on the part of the infant, or dryness and coldness of the surface. 
The respirations are superficial ; the temperature, which falls in most 
infants after birth, does not return to the normal. When the symp- 
toms are fully developed they are seen first in the lower extremities, 



SCLEREMA. 225 

in the calves of the legs and the dorsum of the feet, spreading thence 
to the thighs and involving the suprapubic fat. Rarely the eyelids 
and both upper extremities are involved. 

The skin is oedematous, swollen, and much thickened. In some 
cases the skin does not pit on pressure ; in others the pitting takes 
place, but the skin rapidly returns to the primary condition. The 
color of the skin is either reddish, if the scleroedema has appeared 
before the process of desquamation is complete; whitish, if the 
desquamation of the skin has been completed; or cyanotic, if the 
infant is premature. As the disease progresses the skin becomes 
more oedematous, of a yellowish, transparent color, and in the first 
form the redness of the skin disappears. In the cyanotic form the 
cyanosis increases, the skin assumes a bluish, marbled appearance. 
In the worst forms the skin is so tense that pitting by means of pres- 
sure with the fingers does not occur, or immediately disappears when 
the pressure is released. If the skin is punctured with the needle, 
there is an escape of fluid or yellowish serum. These infants take 
the breast badly. They sometimes emit a peculiar, shrill cry, due, 
it is supposed, to oedema of the vocal cords. 

The temperature in the mild forms may range from 34° to 35° 
C. (93.2°-95° F.) ; in severer forms, from 30° to 32° C. (86-89.6° 
F.), but rarely as low as in fat-sclerema, where it may be 22° C. 
(71.6° F.). A complicating pneumonia, however, may cause a rise 
of the temperature either to the normal limit or even as high as 41° 
C. (105.8° F.). The heart is weak; the pulse may have a frequency 
as low as sixty a minute, and in some cases is not perceptible at the 
wrist. The respirations are superficial, labored, and slow. The 
urine contains albumin, sometimes sugar, and, if the infant is icteric, 
bile pigment ; it may also contain red blood-cells, granular casts, and 
fatty epithelium, and rarely leucin. The disease in most cases is 
confined to the lower extremities, the mons veneris or suprapubic fat. 
and buttocks and lower part of the back, but it may spread around 
to the abdomen, involving its lower part. It seldom occurs in patches 
or small areas. If improvement occurs, the oedema may disappear, 
leaving a condition of the skin resembling fat-sclerema. Under 
these conditions the skin is less wrinkled and oedema of the deeper 
parts disappears slowly. In fatal cases death supervenes without 
any marked symptoms. The infants simply fail, the pulse becomes 
slow, the respiration ceases; children die in apathy and coma. 

Duration and Complications. — Congenital cases may die in a few 
hours; the post-natal may linger from four days to two weeks. Com- 
plications are rare; they have nothing in common with the primary 
disease, and result as a consequence of the reduced circulation and 
liability of these 1 infants \o infection. Hemorrhages occur in the 

15 



226 DISEASES OF THE NEWBORN. 

lung and pleura; lung complications may occur. Effusions have been 
found in the peritoneum and pleura ; the latter especially in congen- 
ital cases. The skin may be the seat of icterus, pustules, ulcers, 
erysipelas, purpura, or gangrene, especially if complicating sepsis is 
present. Decubitus ulcers, ecchymoses, and finally pneumonia may 
occur as a septic complication. 

Morbid Anatomy. — So far as the skin is concerned, the oedema 
postmortem is much the same as during life. The skin, muscles, 
and cellular tissue, not only of the skin, but of the various regions, 
such as the mediastinum and vocal cords, are involved. In fatal 
cases there has been found intestinal catarrh, affections of the lung, 
such as atelectasis ; bronchitis, bronchopneumonia, pleurisy, myocar- 
ditis, fatty degeneration of the liver, spleen, and kidneys, hemor- 
rhages into the lung and tissue of the heart. 

Prognosis. — Clementowsky, who has made a close study of this 
disease, has recorded 152 cases with 52 deaths. The presence, there- 
fore, of this disease does not exclude the possibility of a recovery, 
provided the infant retains a certain amount of constitutional resist- 
ance and the disease is not widespread. 

Treatment. — The treatment of this form of scleroedema being 
much the same as that of fat sclerema, both will be treated under a 
common heading. 

Sclerema Adiposum (Fat-sclerema). — This condition is much 
more common than the scleroedema just described, and is not a dis- 
ease confined entirely to the first days of life, but may occur up to 
the sixth month of infancy. It is doubtful if the disease occurs as a 
congenital condition. If so, it is rare. The affection follows or 
complicates exhausting diseases, and is also seen complicating summer 
diarrhoea, cholera infantum, and pneumonia. If seen as a compli- 
cating condition, it is a forerunner of death. It may be seen not 
only in bottle-fed, but also in the breast-fed infant, the victim of 
these affections. 

Symptoms. — The disease itself begins mostly in the calves of the 
legs, but not necessarily where the loose connective tissue exists, as 
the scleroedema does. The deeper parts are firm ; the skin is not mov- 
able, and has a doughy feel, as though there were nodules of fat 
imbedded in the tissues. Another place of predilection of its appear- 
ance is in .the face, where it is first seen affecting either the tip of 
the nose or the cheeks. The affection is symmetrical. It appears, 
as has been stated, in the calves, involves the dorsum of the feet, 
spreads to the thighs, involves the buttocks, especially the inner parts 
of the thighs, may spread to the upper extremities, lastly involving 
the face. The palms of the hands or soles of the feet, even in the 
severest cases, remain free ; as also the scrotum and penis. 



SCLEREMA. 227 

The skin, when the disease is fully developed, is flat, shining, 
tense, closely adherent to the subadjacent parts, or it may be of a 
yellowish, whitish, lardaceous appearance, or may be ecchymotic, 
cyanosed, or red in areas. When the skin is palpated it has a doughy 
feel, very much as is seen in a corpse. The skin has lost all its 
original resiliency. In some cases pitting on pressure may result, 
but not to the extent seen in scleredema. In some cases, where the 
disease has extended over a large surface, the body may be taken up 
and will remain stiff and extended like a corpse. The respirations 
are very shallow and reduced in frequency, 16 to 18 a minute. The 
heart is weak, its frequency reduced from 80 to 60 or even 30 beats 
a minute. 

The temperature is low (much lower than in the sclercedematous 
form). It may fall to 30°, 26°, or even 22° C. (86°, 78.8°, or 71.6° 
F.). If a complicating infection is present, such as pneumonia, the 
temperature may rise to near the normal. The urine is diminished 
in quantity, dark, concentrated, contains albumin, casts, urates, and 
uric acid. If there is a complicating condition, it is generally one 
of the exhausting diseases, such as summer diarrhoea, cholera infan- 
tum, or septic pneumonia. Exitus lethalis, as in the previous form, 
takes place under conditions of progressive failure of the respiration, 
reduction of temperature, failure of the heart, unconsciousness, and 
coma. 

Morbid Anatomy. — The skin and subcutaneous tissues postmortem 
retain the characteristics seen during life. If cut into, no fluid 
exudes, and very little bathes the surface of the section as compared 
with what is seen in scleroedema, where considerable fluid exudes 
from the cut surface. The tissues are dry (very much like frozen 
fat). Atelectasis, pneumonia, oedema of the lung, pleuritis, peri- 
carditis, hemorrhages, enlarged spleen, and fatty degeneration of the 
liver and kidneys may be present as complicating conditions, with 
or without intestinal catarrh. In the brain, hyperemia and hemor- 
rhages have been recorded. 

Duration. — The duration of the disease is from two to seven days. 

Diagnosis. — To diagnose either of these forms from the symptoms 
just detailed is not difficult ; but I have seen it mistaken for the 
oedema of nephritis. On examination such a mistake can easily be 
rectified, for in nephritis certain features of sclerema are absent, such 
as reduction of temperature, lardaceous, corpse-like feel of the skin, 
the lack of resiliency, especially in the fat sclerema tons form. In 
infants the skin may even retain its original wrinkled appearance, 
and the deeper tissues of the skin have the characteristics described. 
On the other hand, nephritis may complicate scleredema or fat- 
sclerema. 



228 DISEASES OF THE NEWBORN. 

Sclerema must not be confounded with a similar disease which 
occurs in the adult subject and older children. Sclerema of the 
newborn and scleredema do not appear, as in the adult, in patches, 
but involve whole regions and extremities. This condition of the 
newborn must not be confounded with sclerodactylia, which is seen 
in adults and older children. 

Prognosis. — The prognosis of fat-sclerema is not necessarily fatal, 
if primary and not complicated with any exhausting condition; if 
secondary, as has been stated, it is the forerunner of death. 

Treatment. — Inasmuch as these infants have not only a reduced 
temperature, but a tendency toward a constant progressive reduction 
of the internal temperature, they should be put in some form of 
incubator, and the same methods applied as in the care of premature 
infants. Oxygen is administered to stimulate not only the respira- 
tions, but the heart. If the sclerema is not too general the parts 
may be massaged with camphorated oil ; and I have seen some cases 
in which a decided improvement followed such treatment. Cardiac 
stimulants are used to arouse the nagging circulation. The best 
drugs to employ are carTein and strychnin, with or without ammo- 
nium carbonate. To these infants we must give very small doses, 
-J grain of citrate of caffein every few hours, or %oo grain of strych- 
nin, or J grain of ammonium carbonate. In many of these cases 
the act of nursing is impossible, and they must be fed with the pipette. 
If unable to swallow they must be fed by gavage or per rectum. The 
subcutaneous injection of fluids, in my hands at least, has been of no 
avail ; therefore the hypodermoclysis is of very little utility. 

OPHTHALMIA NEONATORUM. 

( Conjunctivitis Blennorrhceica. ) 

Ophthalmia neonatorum is an inflammation of the conjunctiva, 
accompanied by a profuse secretion of pus, and in some cases an 
inflammation of the cornea. It is a specific inflammation of the 
conjunctiva due to the gonococcus of Neisser. From 30 to 40 per 
cent, of the children in the institutions for the blind have lost their 
sight through this disease. 

Etiology. — The infant may be infected during labor or after birth. 
It may be infected immediately after birth, or some time subsequent 
to delivery. In those cases in which the disease appears from twelve 
to twenty-four hours after birth, they may be safely said to have been 
infected in the passage through the parturient canal. In those cases 
infected after birth the symptoms appear in from three to four days 
post partum. Finally, children may be infected at any period in 
the puerperium. 



OPHTHALMIA NEONATORUM. 229 

The sources of infection are the secretions from the parturient 
canal of the mother, or infectious material conveyed to the eyes of 
the infant by the finger of the nurse or accoucheur. The infection 
post partum occurs by direct contact of the gonocoeci with the orbital 
conjunctiva. In institutions, infections are ten times as frequent as 
in private practice, where the disease, at least on the continent of 
Europe, occurs in 0.1 per cent, of births (Silex). 

Symptoms. — From three to five days after birth it is noticed that 
the conjunctivae are red and swollen; there is an injection of the 
sclera, swelling of the lids, and increased temperature of the parts, 
or possibly oedema and profuse secretion, at first of a thin, yellow, 
serous discharge, which after two days becomes thick and creamy. 
The swelling of the lids is quite marked; the eyes are closed. In 
some cases the palpebral conjunctiva protrudes from between the 
orbital fissure and a profuse creamy pus exudes from between the 
eyelids. If the child has icterus, this pus may assume an icteric 
color. The cornea is hazy, covered with secretion, and shreds of 
pseudomembrane may adhere to the palpebral conjunctiva, especially 
in the early stages of the disease, thus simulating diphtheritic infec- 
tion. If not controlled the inflammation of the eye progresses until 
the whole depth of the cornea is involved, resulting in perforation 
and prolapsus of the iris, escape of the humor, and consequent 
panophthalmitis. The constitutional symptoms in these cases consist 
of a lack of desire to nurse on the part of the infant, and a slightly 
elevated temperature. If the infant is premature or the subject of 
any dyscrasia, the constant chilling which takes place as a result of 
cold applications to the eyes results either in a loss of or stationary 
weight. Therefore this disease is more serious if it occurs in bottle- 
fed than in breast-fed infants. 

Duration. — The duration of the disease varies according to the 
intensity of the infection. As a rule, it lasts three or four weeks. 
when subacute, the secretion becomes mucoid or serous. 

Complications. — The complications, so far as the eye is concerned, 
are keratitis, with perforation of the cornea and loss of the eye. In 
some cases arthritis of a gonorrhoeal nature has been observed as a 
complication; in others, vulvovaginitis may result as a complicating 
infection. 

Diagnosis. — The diagnosis presents no difficulties. There is a 
simple inflammation of the eyes occurring in newborn infants which 
is not gonorrhoeal in its nature, but in which the local symptoms are 
not very marked; in faei. so mild as to raise a suspicion at once of 
its non-specific nature. In other eases oi' ordinary non-specific con- 
junctivitis, chemosis, swelling, and oedema of the lids are not marked 
as compared to what is seen in the gonorrhoea] form. The amounl 



230 DISEASES OF THE NEWBOEN. 

of pus secreted is not great, and the course of the disease is, as a rule, 
benign. We should, however, before deciding as to the innocent 
nature of a conjunctivitis in the newborn make a spread of the pus 
on a cover-glass and stain the same for gonococci, as this is the only 
certain method of determining the nature of the disease. In doubtful 
cases a culture will be demanded. Clinically, however, the two forms 
of conjunctivitis are so distinct that we may suspect the one or the 
other from the mildness or the severity of the local symptoms. 

Prognosis. — The prognosis is grave in all cases. A favorable 
issue will always depend on an early recognition of the disease. If 
the disease is recognized late in its course, the prognosis becomes not 
only doubtful, but grave as to the integrity of the organ. 

Treatment. — The physician will understand that above all things 
cleanliness is the first factor in the prevention of this dread affection. 
In private practice, we may be able to judge, from a knowledge of 
the patient and her previous condition, as to the necessity of certain 
measures, which will be mentioned. If we are cleanly, however, 
some authors insist that not only in private practice, but in insti- 
tutions, the severer methods of prophylaxis will remain superfluous. 

We may state that the principal method of prophylaxis in the 
past, and at the present day, is the so-called Crede method of pro- 
phylaxis of gonorrheal ophthalmia, and this consists in the instilla- 
tion of a drop of a 2 per cent, solution of nitrate of silver into the 
eye immediately after birth. In ordinary cases of head presentation 
it is contended that if the parts of the mother are cleansed just before 
the birth of the head, and if after the head is born the eyes are care- 
fully but energetically washed with sterilized water, better results 
are obtained when large numbers of cases are treated than by the 
Crede method. Therefore, although in institutions it may be advis- 
able to apply the Crede method, on account of the number of cases 
which are there treated, it is insisted that in private practice this 
method remains superfluous. A small dish of sterilized water should 
be close by, and while one hand supports the crowning head the other 
should wash the eyes carefully with the sterilized water before the 
child is born, and the complete washing of the eyes can then be 
repeated after the birth of the child. By this, the Kaltenbach, 
method of procedure only 0.3 per cent, of cases to the thousand are 
infected: whereas the combined results of the Crede method have not 
been lower than 0.6 per cent, per 1000, on account of the various 
methods of carrying out the Crede procedure ; though Crede himself 
obtained as low a percentage as 0.1 in 2000 cases. 

The disease once inaugurated, the following treatment may be 
formulated: The eyes are cleansed, every half-hour to an hour, with 
a 1 : 1000 solution of corrosive sublimate. The eye is opened, and 






MASTITIS. 231 

with dry cotton the excess of secretion removed, and then the remain- 
ing secretion washed away with the sublimate solution. Small pieces 
of lint, cut to a size slightly larger than the eye, are kept on ice and 
applied every two to five minutes. The child is kept warm; other- 
wise with this treatment the body may become chilled. A solution 
of 2 per cent, nitrate of silver is dropped into the eye daily. Later, 
when the secretion of pus lessens and the conjunctiva is swollen and 
spongy, a 5 to 10 per cent, silver solution is dropped into the eye and 
immediately neutralized with salt solution. 

Any therapy beyond that just outlined is scarcely within the 
province of the general practitioner; but so important is immediate 
action in these cases that every practitioner should proceed with the 
treatment before calling to his aid an ophthalmic surgeon. If one 
eye alone is affected, it is well to try to save the other eye from 
infection, and there are several methods by which this may be accom- 
plished. A simple method is to close the eye, cover it with cotton, 
enough to fill out the hollow of the eye, and then to cover this cotton 
with a piece of lint. Over this place a piece of gutta-percha pro- 
tective, and bind the eye shut. Such an eye should be looked at 
daily before the affected eye is treated and cleansed. Should it 
become infected, the bandages are removed, and the eye treated in the 
same manner as the affected eye. 

CAKING- OF THE BREASTS. 

Caking of the breasts of the newborn is not uncommon, and must 
not be looked upon as a necessary forerunner of mastitis (Fig. 26). 

If the breasts of the newborn are swollen but not very tense they 
should not be interfered with, as this is caused by an abundant milk 
secretion, which soon diminishes. No attempt should be made to 
express the milk. If milk exudes it should be carefully washed off 
the breast, and the breast protected from traumatism and infection 
by a pad of sterilized gauze. In exceptional cases the breasts seem 
really tense and painful. Under those conditions they may be gently 
massaged once a day. The index finger of the right hand is cleansed, 
anointed with sterilized oil, and the breast is stroked in a circular 
direction for about five minutes. It is then cleansed and covered 
with cotton or gauze, as detailed above. It is not possible in the 
newborn to bandage the breasts tightly, as this procedure interferes 
with the respiratory movements of the chest. 

MASTITIS. 

Mastitis in the newborn is the result of infection ot' the breasts. 
The organ of one or both sides becomes tense and painful, ami the 



232 DISEASES OF THE NEWBORN. 

skin covering the breast becomes red or bluish-purple in hue. There 
are fever and restlessness. After a few days fluctuation appears in 
the breast, generally toward the base of the nipple. 

The treatment at first should be directed toward aborting or 
limiting the inflammation. Nothing is so effective as the applica- 
tion of small squares of lint which have been moistened with a weak 
solution of sublimate, 1 : 10,000, and applied cold. If after a time 
fluctuation appears, incision and drainage are indicated. 

INJURIES INFLICTED DURING BIRTH. 

Among the injuries incident to birth are those of the face. Pres- 
sure of the forceps blade may cause facial paralysis. This, as a rule, 
disappears in time, though in severe injury of the nerves it may 
remain permanent. Indentations of the cranial bones may result 
from the pressure of instruments. In these cases the bone is depressed, 
and in the space between the scalp and bone there is an effusion. 
The edge of the bone surrounding the depression is distinctly felt. 
These depressions need no treatment, as they disappear in time. 

Paralysis. — Traction on the arm may cause a so-called birth palsy, 
which is the counterpart of Erb's palsy in later life. The paralysis 
in these cases sometimes remains permanent. Others recover. As 
a rule, one arm is affected, but in rare cases both arms may be par- 
alyzed. The symptoms are characteristic. In a few days or at a 
later period after birth it is noticed that the infant does not move 
one or the other arm (Fig. 28). The affected limb hangs loosely 
and without power of motion. The fingers or hands may be mobile. 
The affected arm is cold and the hand may be bluish in tint. After 
a time atrophy of the muscles about the shoulder- joint may set in. 
The bony prominences then come into relief. If the arm does not 
recover power, the muscles continue to atrophy, and there may be 
subluxation of the head of the humerus at the shoulder-joint. The 
child in these cases always holds the injured arm with the sound 
one, in order to protect and support it. At the early period the reac- 
tions of degeneration are present, and if the muscles recover, the 
reaction to the galvanic and faradic current becomes normal. If 
recovery does not take place, the disappearance of galvanic and faradic 
irritability of muscle goes hand in hand with the muscular atrophy. 

Treatment. — The treatment of these obstetrical palsies is similar 
to that of Erb's palsy. The arm is protected from traumatism. 
Massage is performed within two weeks after injury, and after four 
weeks the faradic current is applied to cause muscular contraction. 
Electricity is applied for a short space of time daily. The progress 
of these cases can best be judged under treatment. As a rule, recovery 



PLATE VIII 




't 



M 




tm. 



x- 
■ j 



I 

M 



w* I 



Torticollis Originating in a Traumatism at Birth. Hematoma 
of the Sternomastoid Muscle. 



INJURIES INFLICTED DURING BIBTE. 



233 



takes-place in a few weeks. In other cases recovery may be delayed. 
In a third set of cases recovery never takes place. The galvanic 
and faradic contractility disappears from the muscle and nerve, and 
permanent atrophy and disability remain. In the se cases there is 
also retarded growth of the bone. It may be mentioned that in rare 
cases pressure of the forceps blade has caused a paralysis of the hypo- 
glossal nerve and consequent paralysis of one or other half of the 
tongue. Every time the infant nnrses there will be in such cases 
great difficulty in swallowing. The infant will cough and become 

Fig. 29. 




Birth palsy affecting the left arm, atrophy of the muscles about the shoulder. 



cyanosed. These infants must be nursed slowly or with a jnpette 
until the tongue has recovered power. 

Hematoma of the Sternomastoid Muscle. — This affection is the 
direct result of traumatism during delivery. As a rule, it is seen 
in cases of breech presentation in which traction has been exerted on 
the after-coming head. 

Symptoms. — In the majority of the cases coming under my obser- 
vation the sternomastoid muscle of the right side was affected (^ Plate 
VIII.). The infant holds the head on one side. The muscle of the 
affected side is contracted, and the position of the head is thai seen 
in torticollis. A hard nodule is felt along the inner border of the 
sternomastoid muscle, about the junction of the lowerthird and upper 
two-thirds. The tinner is usually the size of a small hazelnut, bur 
maybe much larger. Manipulation causes pain. The skin over the 
tumor is movable and net discolored. 



234 DISEASES OF THE NEWBOBN. 

Course. — The progress of the affection in all of these cases is much 
the same. The tumor becomes smaller as the exudate is absorbed, 
but the torticollis persists, although in time this may disappear. The 
nature of these tumors is probably that of a hematoma caused by 
rupture of muscular fibres and bloodvessels. 

Treatment. — The treatment is simple. At first the tumor should 
be let alone. After a few days gentle massage with the fingers 
moistened with oil is permissible. When the growth hardens the 
massage may be more vigorous, and be supplemented with an attempt 
at each sitting to turn the head gently to the opposite side and thus 
stretch the contracted muscle. Cases which do not recover must be 
treated by surgical means later in life. 

Cephalhematoma. — Cephalhematoma is an effusion of blood 
between the pericranium and the skull-cap. The pericranium and 
scalp are raised into a distinct tumor. In external cephalhematoma 
the effusion is between the pericranium and the skull; in internal 
cephalhematoma it is between the dura mater and the skull. Kee 
found both forms present in the same patient in 9 out of 20 cases. 

Symptoms. — There is a tumor varying in size from that of a hazel- 
nut to that of an orange, of elastic consistency, situated in most cases 
on one or the other parietal bone. It is round, elongated, or kidney- 
shaped. It covers part or the whole of the bone, but never extends 
beyond the sutures. The skin over the tumor is not sensitive to the 
touch, is normal or slightly bluish in color, and is perfectly movable 
over the tumor. After a few days the circumference of the tumor is 
bounded by a distinct wall, at first soft, but later of bony hardness. 
The general health of the infant remains good unless there is a com- 
plication. This blood tumor appears two or three days after birth. 
At first it is tense, but afterward becomes softer and doughy to the 
touch. It reaches its maximum size in from six to eight days. It 
begins to diminish in the second week, and disappears by the fifteenth 
week. The tumor is either absorbed or there is a proliferation of 
bone, which remains as an exostosis. At this time crepitation resem- 
bling that of parchment is felt. Around the former tumor a thin 
wall of bone is found. 

Occurrence. — These tumors are not common. Hennig found 230 
cases in 53,506 births, or 0.43 per cent, of the whole number. Hof- 
mokl's statistics give a like figure. Most of the cases are vertex 
presentations. The cephalhematoma usually occurs on the right 
parietal bone, and may follow easy as well as difficult labors. It is 
present oftener in boys than in girls, and is seen in premature infants 
as well as full-term babies. It has been observed in breech cases, 
especially if forceps has been applied to the after-coming head. 
These tumors may occur on both parietal bones of the infant. In 
such cases the sagittal suture distinctly separates the two tumors. 



INJURIES INFLICTED DURING BIRTH. 235 

Complications. — Internal cephalhematoma, or cerebral hemor- 
rhage, may complicate the external tumor. In such cases there has 
been a difficult labor with the application of forceps. The majority 
of the infants thus affected die. Suppuration of the tumor may take 
place, or diffuse cranial phlegmon may result fatally. A section of 
a cephalhematoma shows the scalp to be studded with punctate hem- 
orrhages. The pericranium is bluish and covered with hemorrhage-; 
and is separated from the skull by a collection of fluid blood under 
great tension. The bone beneath is rough or covered with a few 
clots. A bony wall is seen around the circumference of the tumor. 
It is a periosteal formation. After a time the bone and the inner 
surface of the pericranium become coated with a gelatinous exudate, 
which is subsequently converted into bone. In some cases quite an 
extensive bloody effusion is found between the dura and skull. 

The situation of the cephalohgematoma always corresponds to the 
position of certain natural fissures which exist in the posterior part 
of both parietal bones, running from the sagittal suture. In the 
occipital bone these fissures radiate from the lateral fontanelles and 
separate the upper and the inferior part of the occipital bone. 

Pathogenesis.- — A cephalohsematoma is the result of the bursting 
of a small vessel between the periosteum and bone, and at the situation 
of the caput succedaneum. Hence the frequent formation of the 
tumor on the right parietal bone. It is most common in first-born 
infants. Asphyxia of the infant favors the formation of the tumor. 
Cephalohsematoma may also occur as a part of the hemorrhagic 
symptomatology in general diseases, such as syphilis, sepsis, and 
Buhl's disease. 

Diagnosis. — The diagnosis is made from the presence of an elastic 
fluctuating tumor distinctly limited by suture and surrounded by a 
ring or wall. A caput succedaneum is oedematous and bluish, is seen 
immediately after birth, passes beyond the sutures, does not fluctuate, 
and disappears shortly after birth. A hernia of the brain does not 
fluctuate, grows tense when the infant cries, and shows respiratory 
fluctuations and pulsation. It can be reduced. Abscess of the scalp 
is painful, hot, and red; the phlegmon spreads over the whole scalp 
and is accompanied by oedema of the whole region. If cerebral 
symptoms are present with a cephalohsematoma, they point to corre- 
sponding internal effusion or cerebral hemorrhage. 

Prognosis. — The prognosis is good if there is no internal tumor 
or cerebral hemorrhage, or if infection of the external tumor with 
resulting abscess does not occur. Even the la tier, however, does not 
precludo the possibility of recovery. The prognosis is bad it the 
cephalohsematoma is pari of -a general hemorrhagic condition, as in 
syphilis, fatty degeneration, or sepsis. 



236 



DISEASES OF THE NEWBORN 



Treatment. — Uncomplicated cephalohsematomata are absorbed if 
let alone. If abscess occurs, the tumor should be opened under anti- 
septic precautions, evacuated, and the sac packed with iodoform gauze. 

On the other hand, even in the early stage, the tumor may be 
large and tense, and cerebral symptoms may be present. Such effu- 
sions of blood may communicate with an internal tumor through 
the parietal or occipital fissures mentioned. In such very excep- 
tional cases aspiration to relieve internal pressure may be justifiable 
(Eunge). 

Note. — For other injuries attending birth see article Cerebral Palsy or Little's 
Disease. 



SECTION IV. 

DISEASES DUE TO DISTURBANCES OF NUTRITION. 

RACHITIS. 

(Rickets.) 

Rachitis is a disease of nutrition causing well-marked changes 
in the structure and form of the growing bones. It is peculiar to 
infancy and childhood and does not occur after the skeleton is formed. 

Etiology. — There are two forms of rachitis, the congenital or foetal 
and the post-natal. 

The occurrence of congenital, foetal, or intra-uterine rachitis is 
still a subject of much difference of opinion. According to some 
authorities (Kassowitz), 80 per cent, of the infants of the Vienna 
Maternity Hospital show evidences of rachitis. Epstein at one time 
demonstrated to me the great frequency of rachitic deformity at the 
costochondral junction of the ribs, in the infants of the Maternity 
Hospital in Prague. 

Congenital Rachitis. — There can be no doubt of the existence of 
such a condition as rachitis in utero, or congenital rachitis. In these 
cases the infant at birth has craniotabes, or, if closely examined, the 
rosary and other marks of the true rachitic process on the long bones 
may easily be made out. We must not confound such cases with 
what has been called foetal rickets. The latter term, as will be seen, 
has been practically abandoned, and was at one time applied to cases 
of chondrodystrophia. It is not at all a rachitic process, and has 
nothing in common with rachitis. Yirchow insists that foetal rachitis 
in the true sense is rare, and that an anomaly in the development of 
the primordial cartilage has been mistaken for rachitis, with which it 
has nothing in common. 

Hemorrhagic rachitis is a term applied by some authors to Bar- 
low's disease or infantile scurvy. Rachitis is for the most part post- 
natal, and its onset occurs most frequently during the first year of 
life. It is rare after the third year. The sexes are equally subject 
to the disease. A moist climate favors it. It is very common in 
Germany and Austria, and is rarely met in southern Asia or Central 
America. Fischl insists that ii is peculiar to some races of people. 
and Snow, of Buffalo, has shown that Italians living in America 
are peculiarly subject to it. It is most common among civilized com- 
munities, in which infants, especially those o( large cities, are fed 

287 



238 DISEASES DUE TO DISTURBANCES OF NUTRITION. 

upon substitutes for breast milk. On the . other hand, breast-fed 
infants may develop rachitis, but in such cases investigation of the 
milk by Pfeiffer and others has not resulted in the discovery of any 
peculiarity of the milk which might be looked upon as a causative 
factor. Rachitis develops in infants who have been weaned from the 
breast early and fed on artificial foods or sterilized milk. The early 
introduction of meats and solid food into the dietary of the infant has 
been cited as an etiological factor. 

That syphilis is a direct causative agent in rachitis (Parrot) can 
no longer be accepted. Heredity does not seem to exert any influ- 
ence. There are many theories as to the active and immediate 
causes. The principal theories are those which presuppose the lack 
of some element, such as phosphates or lime salts, in the food, and 
those that trace the processes of rachitis to a disturbance of nutritive 
functions caused by an increase of certain acids (lactic) in the 
stomach, a diminution of others (hydrochloric) and resulting intes- 
tinal functional irregularities (Monti, Zander). The intestinal dis- 
turbances cause the elimination of certain salts from food, hence the 
blood fails to receive what is necessary for the structure and forma- 
tion of the bones. 

Morbid Anatomy. — Rachitis is anatomically characterized by proc- 
esses which cause an increased resorption of bone, deficient calci- 
fication of cartilage, and the formation of a characteristic tissue — a 
deficiently calcified bone, the so-called osteoid tissue (Ziegler, Kasso- 
witz, Schmorl). The increased resorption consists in an augmenta- 
tion of the number of areas of lacunar absorption. In marked 
rachitis the greater part of the bony skeleton is lost. The cortical 
area of the long and of the short bones becomes osteoporous. A 
large part of the lamellae of the cancellous bone is absorbed and dis- 
appears. In the flat bones the arrangement of outer and inner table 
separated by the intervening diploe is lost. The bone tissue is re- 
duced to a few lamellae. At the zones of periosteal and medullary 
ossification, the lamella? are replaced by osteoid tissue. This tissue 
is a new formation devoid of lime salts. 

The marrow of the osteoid tissue formed from the periosteum or 
medullary canal consists of a reticulum of striated connective tissue 
rich in bloodvessels and enclosing free round cells. Beneath the 
periosteum of the cranial and long bones there is formed, because of 
these changes, a spongy vascular tissue which is resistant to pressure 
and may be cut with a knife. While the rachitic process lasts, no 
lime salts appear in the lamellae of osteoid tissue, but as soon as the 
disease has spent itself those salts appear in the centre of the lamellae. 
Complete recovery results in calcification of these lamellae, which 
being proliferated leave the bone hardened and very much thickened. 



RACHITIS. 239 

The pathological change in the endochondral ossification consists in 
an entire absence of a calcification zone. In severe rachitis, all signs 
of the deposit of lime salts are absent. There is a widening of the 
zone of proliferation of cartilage cells, and also of the columns of 
hypertrophied cartilage cells. There is lastly an irregular formation 
of vascular marrow-spaces, which grow here and there into the car- 
tilage from the bone. Thus at the junction of cartilage and bone. 
there is in the long bones no distinct line of ossification. The red 
marrow-spaces extend for varying distances into the cartilage. 

The abundant growth of bloodvessels extending from the peri- 
chondrium into the cartilage is accompanied by the substitution of 
osteoid tissue and marrow-spaces for the cartilage proper, as in 
periosteal and medullary ossifications. In rachitis the cartilage is 
never completely absorbed by osteoid tissue. Thus, on section, the 
bone shows, nearest the cartilage, the zone of proliferating cartilage- 
cells with hypertrophied cells in columns ; next to this is the zone 
of osteoid tissue in lamellae in which few lime salts are deposited. 
Nearer the bone are lamellae of osteoid tissue, in the centre of which 
fully formed bone is deposited. 

The lamellae of osteoid tissue differ from those of normal bone in 
being much thicker and more abundant. The osteoid tissue is very 
resilient and easily bent, hence this property of rachitic bones. The 
process leaves the bones much thickened, especially at the epiphyseal 
extremities. The deformities of the chest, extremities, pelvis, and 
spine can thus be traced to the tendency of the rachitic bone to bend 
on pressure and traction. The effects of the process on the shape of 
the cranium and the delay in the formation of the teeth may thus be 
easily accounted for. 

Among other gross lesions connected with the clinical picture of 
rachitis is enlargement of the spleen. The organ may be very large 
and easily palpated below the border of the ribs. Sasuchin found 
that of 66 cases of rachitis, the spleen was enlarged in 12 to 15 per 
cent. The changes in the organ consisted in thickening of the cap- 
sule and proliferation of the connective tissue of the organ, thickening 
of the walls of the arteries, atrophy and obliteration of the Malpighian 
bodies, and anaemia of the organ. This important blood-distributing 
organ is thus compromised. The spleen may be increased to two and 
a half times its normal size. 

The liver may also be apparently enlarged. During life the 
enlargement of the liver may be more apparent I ban real. The chest, 
if narrow and deformed, may cause downward displacement and rota- 
tion of that organ. In rachitic infants the lymph-nodes are more 
apparent on palpation than is normal. They, however, are never 
increased to the size attained in tuberculosis, syphilis, or eruptions 



240 DISEASES DUE TO DISTURBANCES OF NUTRITION. 

of the skin, such as those of the exanthemata. The blood may show 
the changes of extreme simple anaemia — an increase in the nucleated 
red blood-cells and other signs. 

Brain. — Slight or marked hydrocephalus is frequently found in 
rachitis. The relation between the two conditions is not clear. If 
the infant dies of an intercurrent disease, changes of a chronic 
catarrhal character may be found in the gut and signs of bronchitis 
or persistent bronchopneumonia in the lungs. These conditions follow 
the changes in nutrition which cause the rachitic processes elsewhere. 

Symptoms. — The most marked and general symptoms of rachitis 
are changes in the bony skeleton. 

The Head.- — The shape of the rachitic head is characteristic. 
The frontal bone bulges, giving the infant a prominent forehead. 
The parietal bones have a flare, caused by the formation of bosses 
at the centres of ossification. The whole head has a cuboidal 
shape, which, with the proportionately small face, gives a character- 
istic appearance. The disturbances in bone formation cause the 
appearance of soft spots, especially in the vicinity of the lambdoidal 
suture. These (craniotabes) may be membranous in structure. They 
rarely appear on the frontal bones in the vicinity of the coronary 
suture. The spots of craniotabes appear in infants who develop 
rachitis before the sixth month (Monti), rarely after this period. 
They take four or five weeks to develop fully. In developed rachitis 
the occiput is flat and devoid of hair (Plate IX.). The anterior 
fontanelle, 1 which normally closes between the fifteenth and the 
eighteenth month, remains open for a long time, in some cases until 
the third or fourth year, or even to the sixth. The sutures are also 
slow in closing. The coronary sutures may remain open for two, and 
the longitudinal suture for three years. The lambdoidal suture does 
not in some cases close until the eighteenth month. 

If the thorax is affected by rachitis, the circumference of the head 
will exceed that of the chest. The lower jaw has an angular deform- 
ity, described by Fleischmann. This consists in a bending of the 
body of the jaw at the situation of the canine teeth. The body of 
the jaw is also rotated internally on its horizontal axis. If rachitis 
begins before the sixth month, dentition is delayed for periods vary- 
ing up to a year and a half. I have a record of a case in which the 
first tooth appeared at the twenty-fourth month. If rachitis develops 
after appearance of the first teeth, the succeeding ones appear later 
than is normal. The structure of the teeth suffers. They show 

1 While the lateral and posterior f organelles close during the first months of 
infancy, the anterior fontanelle increases in its longitudinal and transverse diameter 
with the growth of the cranium up to the twelfth month. The growth of the 
anterior fontanelle was first observed by Elsasser. Although denied by Kassowitz 
it has been recently proved by Ehode that the contention of Elsasser is correct. 



PLATE IX 




Rachitis. Showing the cuboidal shape of the head, the 
thoracic deformity, the beaded ribs, the protuberant abdo- 
men, and the enlarged lower end of the radius. 



RACHITIS. 



241 



erosions, are easily broken, and become carious quickly. This is due 
to imperfect formation of enamel or dentine. Sometimes after their 
eruption, the incisors show a well-marked incurvation at the free 
border, which is due to erosion or breaking of the tooth. 

Thorax. — The thorax shows characteristic deformities. Rachitis 
of the thorax in most cases develops in the second half year, and 
may continue into the third year. The first marked sign is the 

Fig. 30. 




Rachitic deformity of the spine. Uniform curvature backward. 



appearance of the so-called rib rosary. This is a thickening of the 
costochondral junction of the rib, in which the rachitic processes 
above described are very active. Deformity of the thorax follows in 
course of time. The thorax becomes prominent at the sternum and 
flattened in the midaxillary region from the axilla to the free border 
of the ribs. (Plate IX.). There is a distind incurvation of the 
thorax above 1 , and a flaring below. The thorax is much narrowed at 
the clavicles, with a Earing outward of the lower ribs. Respiration, 
especially inspiration, is much interfered with. The sides of the 
16 



242 



DISEASES DUE TO DIS1TEBAXCES OF NU TUITION. 



thorax are drawn inward at the diaphragm at each inspiration. In 
an attack of severe bronchitis or bronchopneumonia, the drawing 
inward of the sides of the chest becomes still more marked. In some 
cases the sternum alone is affected. There is a sinking of the ster- 
num, with resulting chest deformity. Some forms of rachitis affect 



Fio. 31 




Angular deformity of the spine, due to Pott's disease, as distinguished from the 
deformity due to rachitis. 



only the ribs or part of the thorax. While the rachitic process is in 
progress, the chest circumference does not increase; it begins to do 
so when the disease has run its course in the thorax. 

Pain. — When the infant is raised from the chair or crib, it cries. 
This is the result of the painful nature of the rachitic process in the 



RACHITIS. 243 

bones. Forcible percussion of the chest will cause pain. On account 
of the deformity of the chest and the consequent interference with its 
physiological functions, the lung is prone to contract infections, such 
as bronchitis and bronchopneumonia. Atelectasis is also a common 
complication. The clavicle becomes bent and fractures on the slight- 
est traumatism. At the termination of the rachitic process, the 
clavicle and scapula? are much thickened. Virchow has shown that 
the scapula becomes the seat of an angular deformity. 

Spine. — On account of the relaxation of the ligaments of the 
bodies of the vertebra? and of the rachitic processes in the bodies of 
the bones themselves, there is in most rachitic infants a bending back- 
ward of the dorsolumbar spine (Fig. 30). The curvature is very 
marked when the infants are held in the arms. It differs from 
deformity due to Pott's disease in that it is not angular and in that 
the spine can be straightened and even curved forward with ease 
(Fig. 31). 

Lateral curvatures of the spine are also found. If the spinal 
deformities occur early in infancy, they disappear as the rachitis 
heals and the ligaments and muscles regain a normal tonicity. On 
the other hand, should the rachitic process attack the spine late in the 
third or fourth year, the deformities are perpetuated. This is espe- 
cially the case if the pelvis is also affected at that time (Monti). 

Pelvis. — The pelvic deformities which result from rachitis are 
chiefly flattening of the pelvis, and the pseudo-osteomalacic pelvis. 

Upper Extremities. — The epiphyses are much swollen and, in 
rare cases, painful. The wrist is flat and much broadened. If the 
rachitis is elsewhere not marked, the physician should be careful not 
to mistake a normal enlargement in this situation for rachitis. In 
exceptional cases, the elbow and shoulder-joint show similar changes. 

On account of the traction of the flexors and pronators, the fore- 
arm may be incurvated and the bones twisted on their longitudinal 
axes. The result is a more or less fixed position of pronation in the 
forearm. The arm is rarely curved in this manner, but it may, like 
the clavicle, be fractured after slight traumatism. As a result of 
rachitis and deformity, the growth of the bone in length is much 
interfered with. 

The phalanges are sometimes the seat of the rachitic processes. 
In some severe cases I found all the phalanges thickened in the dia- 
physes. These cases bear a very close resemblance to dactylitis 
syphilitica, especially as there is pain on pressure (Fig. 32). 

Lower Extremities. — The deformities of the lower extremities 
are more marked than those oi' the upper ones. On account of the 
pain experienced, the infants refuse to stand; they will draw the 
extremities up underneath the abdomen, it' any efforl is made to 



2 44 



DISEASES DUE TO DISTURBANCES OF NUTRITION. 



make them do so. In other cases, when attempts are made to stand, 
the weight of the body and the muscular traction (Kassowitz) cause 
deformity. The femur, tibiae, and fibulae curve outward, giving the 
so-called " bow-leg" deformity (Plate X.). This may in extreme 
cases result in a deformity of the heads of the bones entering into the 
formation of the knee-joint. The ankle-joint may suffer a varus 
deformity. The femur and tibiae may curve inward, and a knock- 
knee deformity result. In all cases, there is relaxation of the liga- 
mentous joint-structure. The tibia sometimes becomes much thick- 



Fig. 32. 




Rachitic bands, showing bowing and thickening phalanges of fingers (author's case), 



ened and curves anteriorly, giving the so-called " sabre " deformity. 
It may be twisted on its longitudinal axis. I have seen severe 
rachitis of the femur and tibia result in multiple fractures. 

The deformity at the hip-joint, which later in life follows changes 
in the angle made by the neck of the bone with the shaft of the 
femur (coxa vara), is believed to be due (Whitman) to rachitis. 
The children are late in walking. The musculature is weakened 
through disuse. 

When the children assume the sitting posture, they cross the lower 
extremities in tailor fashion. In the majority of cases of rachitis, 
the abdomen is protuberant. As a result of the defective nutrition, 
the musculature of the intestine is weakened in the same manner as 
that of the extremities. Tympanitic distention is the rule. 

Intestinal Disturbances. — Intestinal disturbances are common in 



PLATE X 




Rachitis. Showing the deformity of the thorax and 

marked bowing of the tibiae, 



EACHITIS. 245 

rachitis, but are not a result of the process. Henoch shows that 
rachitis may be present with an apparently normally functionating 
intestine. 

Spleen. — The spleen is enlarged in many cases of rachitis, but 
retrogrades to the normal size after the disease has run its course. 

Blood. — The blood shows the changes found in ordinary mild or 
severe simple anaemia. 

Liver.- — The liver may be slightly enlarged. 

Anosmia. — Ansemia of the skin and mucous membranes is fre- 
quently found. It may be so extreme as to cause the skin to have a 
yellowish waxy hue. Rachitic children perspire freely at night, espe- 
cially about the head. Unless the skin is kept scrupulously clean, 
sudamina, furuncles, and eczema of all kinds will result. 

Nervous System.- — There is no doubt that certain nervous affec- 
tions, such as tetany, laryngismus stridulus, attacks of inspiratory 
apnoea, spasmus nutans occur frequently in combination with rachitis. 
Some authors (Kassowitz, Jacobi, Escherich) trace a distinct etiolog- 
ical connection between these conditions of instability of the nervous 
system and rachitis. 

Hydrocephalus. — Hydrocephalus occurs in rachitic subjects. In 
cases of severe rachitis, an appearance of mild hydrocephalus is given 
to the face by a downward depression of the eyeball. The sclera of 
the eyes is thus slightly exposed. The appearance seems to be caused 
by a depression of the orbital plates of the frontal bone by the over- 
lying frontal lobes of the cerebrum. In many cases of severe rachitis, 
the wide fontanelle, its tenseness, and the open coronal and temporal 
sutures give a picture like that of a non-progressive, mild hydroceph- 
alus which is simply a feature of the nutritive disturbances taking 
place in the brain as elsewhere. 

Severity of the Affection. — The symptoms above detailed are not 
all present in cases of rachitis. In some cases there are only very 
slight signs of the disease, such as a slightly cuboidal shape of the 
head or a scarcely appreciable bending of the ribs without any 
deformity. In such cases even an expert may be in doubt as to the 
presence of swelling of the epiphyses. In other cases an intercurrent 
affection, such as tetany, will cause the physician to seek for signs 
of rachitis, which may be so slight as to have previously escaped 
notice. Craniotabcs is sometimes absent in marked cases of rachitis. 
Delayed dentition is not the rule. Rachitis may be very evident in 
cases in which the teeth appear in their normal order. 

Duration. — In such a disease as rachitis ii is to be expected that 
the duration of the affection will vary greatly. It may last months 
in some cases, in others years. The firsl favorable sign is the attempt 
of the infant or child to walk, but children with marked and progres- 
sive rachitis sometimes walk early. 



246 DISEASES DUE TO DISTURBANCES OF NUTEITION. 

Increase in weight and in the chest circumference, an improve- 
ment in symptoms, such as anaemia and intestinal disturbances, and 
the cessation of pulmonary complications are indications that the 
disease has come to a standstill. 

Diagnosis. — The diagnosis of rachitis before the development of 
the physical signs in the bones of the head, chest, and extremities is 
scarcely possible. Monti thinks that an increase of lactic acid in the 
stomach contents is, if there are intestinal disturbances, strong pre- 
sumptive evidence of early rachitis, but the increase of lactic acid may 
be temporary, and the general practitioner will find it hard to esti- 
mate. Once the bone symptoms develop, there is no difficulty. In 
cretinism, Mongolian idiocy, and syphilis, there are changes in the 
bones which very closely resemble those seen in simple rachitis. Yet 
in all these conditions there are other signs which will make the 
diagnosis clear. In syphilis, rachitis is frequently an accompanying 
condition. There is no etiological connection between the two affec- 
tions. In every case of tetany, spasmus nutans, laryngismus, inspira- 
tory apnoea, or eclampsia, the physician should not fail to look for 
evidences of rachitis. The improvement in these conditions will 
often depend on the management of the rachitis. 

If the infant cannot stand, the limbs may exhibit a variety of 
pseudoparalysis. Paralysis may be excluded by making an electrical 
muscle test. Although infants with rachitis will not stand, they 
move the lower extremities vigorously when lying down. This is not 
the case in the palsies ; the f aradic and galvanic muscle tests and the 
presence of the normal reflexes will fix the diagnosis. In severe cases 
of cranial rachitis, it is not always an easy task to exclude hydro- 
cephalus. While marked hydrocephalus presents no difficulties of 
diagnosis, a slight hydrocephalus is not always apparent. In such 
cases the head circumference is measured once a month. An abnor- 
mal increase in the circumference, a wide tense fontanelle, and open 
sutures indicate hydrocephalus. 

The Blood. — Through a study of the blood in rachitis Morse has 
come to the conclusion that anaemia of any form may exist. It is 
generally an anaemia in which the number of red blood-cells is normal 
or nearly so. The haemoglobin is reduced, and there is a consequent 
reduction in specific gravity. There is leucocytosis, especially in the 
cases with splenic enlargement. 

Rachitis Tarda. — Rachitis tarda is a term applied by Kassowitz 
and Genser to those cases which, instead of running their course in 
two or at most three years, continue in the active stage for eight, ten, 
or even twelve years. Kassowitz and his pupils record cases of florid 
rachitis at the tenth and twelfth year. I have seen a case of florid 
rachitis in a female child eight years of age. She had all the signs 



RACHITIS. 247 

of rachitis of the head, thorax, and arms. The lower extremities 
were permanently crossed in tailor fashion. The bones wore painful, 
and those of the lower extremities were the seat of multiple fractures. 
The teeth were decayed. In Genser's case the milk teeth having 
decayed and fallen out, the permanent ones failed to appear. 

Occurrence. — West has demonstrated that rachitis in the United 
States is not confined to negroes and immigrants. He has shown 
that its greatest frequency is among the natives of Eastern Ohio. 

Prognosis.- — If rachitis is not complicated by any intercurrent 
affection, the prognosis as to life, even in the severe forms, is gener- 
ally good. On the other hand, an intercurrent affection, such as per- 
tussis or bronchopneumonia, is likely to run a severe course and prove 
fatal in a rachitic subject. If the rachitic process is complicated by 
nervous disorders, it is frequently fatal. Sudden death in eclampsia, 
tetany, or laryngismus is not uncommon. 

The prognosis as to deformity will depend on the severity of the 
affection. Subsequent treatment will not always correct deformity 
of the pelvis and long bones. The conditions often remain perma- 
nent. Fortunately rachitis in this country is not among the native 
born of so severe a type as in Germany, Austria, and Switzerland. 
If marked hydrocephalus is a complicating condition, the prognosis 
is bad. 

Treatment. — The treatment of rachitis differs greatly in different 
countries, but there are certain fixed principles upon which all methods 
are based. Prophylaxis is an important element in all methods. An 
infant at the breast should not be weaned too soon if the breast milk 
is sufficient in quantity and the infant is increasing in weight. 
Weaning should not be attempted until the ninth month. If it is 
done in the fall or winter, the milk should be obtained as soon as 
possible after the time of milking. There is no need of sterilizing 
the milk if it has been collected with care. It is at most pasteur- 
ized. Cows' milk should be diluted so that the fat percentages may 
be low. Beef -juice if well borne may be given even before the twelfth 
month of infancy. At the eighteenth month meat is allowed as also 
vegetables, especially peas and spinach. When the breast milk is 
insufficient, it should be supplemented by the requisite number of 
artificial feedings. Rachitic infants do better on two breast-feedings 
a day with several artificial feedings, than on artificial feeding alone. 
Cows' milk is the substitute for the breast. It should be properly 
prepared. Many severe forms of rachitis can be traced to the use of 
infant foods. 

Artificially fed infants should, after the sixth month, be allowed 
a limited amount of fresh fruit juice once a day. Orange juice is 
best, but cannot be borne bv all infants. An Infant should not be 



248 DISEASES DUE TO DISTURBANCES OF NUTRITION. 

allowed to become inordinately constipated. In other words, treat- 
ment is directed toward eliminating all predisposing factors to the 
development of the disease. Some breast-fed infants do not thrive. 
They develop serious disturbances of nutrition and colic, remain sta- 
tionary in weight, and have irregular and green curdy movements. 
In such cases, the infant should be weaned in part from the breast or 
given another wet-nurse. Damp, ill-ventilated dwellings predispose 
to the development of rachitis. 

Bathing. — Young infants should not be bathed in water which is 
much below the temperature of the body. Such bathing prevents 
increase in weight and causes disturbances of nutrition. The tem- 
perature of the bath should be practically the same throughout in- 
fancy. An infant cannot be hardened without disturbing metabo- 
lism. The addition of sea salt to the bath water is advised by some 
physicians, and brine baths are in general use. There are other 
kinds of baths which contain iron, but I have had no experience with 
them. They are not used in America, but are in vogue in European 
countries. 

Living at the sea-coast is believed to exert a very favorable influ- 
ence upon rachitic infants and children. On the other hand, if there 
are adenoids or affections of the chest and lungs, such as bronchitis 
of a chronic variety, the humid atmosphere of the coast is not likely 
to be beneficial, and mountain resorts are better. 

Medicinal Treatment. — Cod-liver oil has long been a favorite 
drug in the treatment of rachitis. It should be given in the emulsion 
with the hypophosphites of lime and soda. An infant a year old 
should take half a teaspoonful three times daily. In intestinal dis- 
turbances, it should not be administered, for fear of aggravating the 
symptoms. The external application of the pure oil to the body can 
hardly be useful, since it certainly interferes with the metabolism of 
the skin. 

Iron in the form of the hypophosphate, grain j (0.06) given four 
times a day, or the saccharated carbonate, grain ij (0.12) three times 
daily, is of great utility. The pomate of iron or the more digestible 
peptonates of iron and manganese are much used. The combination 
of thyroid extract and iron has, in some cases of extreme anaemia 
with enlarged spleen, been of great utility. I have used this combi- 
nation only in cases where there was extreme anaemia with rachitis : 

Thyroid ext gr. £(0.03). 

Sacch. carb. iron gr. iij (0.2). (Heubner.) 

Tabes pulv. t. i. d. 

Henoch has advocated the use of thyroids in the advanced cases of 
rachitis. I advise the cautious use of thyroids in combination with 
iron in selected ambulatory cases. 



RACHITIS. 249 

The lactophosphate of lime is advised by some authorities, hut 
is of little value. 

It has been shown by Kassowitz and Wegner, and confirmed by 
Virchow, that in the lower animals phosphorus administered in suffi- 
cient dosage causes an increased activity in the processes at the 
epiphyseal ossification zone. The bone becomes more compact, but 
there is neither an increase of its diameter nor deformity. Kasso- 
witz has contended that the same results are obtained in the human 
subject. On this question, there is wide difference of opinion. Jaeobi 
was among the first in this country to administer phosphorus as a 
remedy for rachitis. He especially advises its use in cases of cranio- 
tabes. I have found that some children do well on it, while in others 
it causes gastric and intestinal disturbances. I have used the emul- 
sion of lipanin, so much recommended by Kassowitz, as a vehicle for 
the phosphorus. Enough of the phosphorus is put into the oil to 
make a teaspoonful of the emulsion equal to /4so grain (0.00024). 
Thompson's solution of phosphorus may also be used. Preparations 
of phosphorus, even those made with oil, deteriorate. Kassowitz 
advises the formula to be made up with recently dissolved phosphorus. 

There are those who, like Henoch, Monti, and Heubner, regard 
the phosphorus treatment of rachitis with distrust. The treatment 
of rachitis with glandular extracts is still a matter of empiricism. 
The treatment of the convulsions of laryngismus will be discussed in 
the section on that condition. 

Surgical Treatment.- — It is not within the scope of this book to 
dilate on the surgical or orthopedic management of rachitic deformi- 
ties. It is, however, proper to state that it is neither right nor 
necessary to place every infant with marked spinal curvature due to 
rachitis in a plaster jacket. A young infant with marked backward 
curvature of the spine will gradually lose this deformity as its 
muscles improve in tonicity, but if placed in a plaster jacket will 
probably develop a subacute bronchitis or pneumonia. The lung is 
insufficiently inflated as it is, and becomes much more so if the soft 
thoracic walls and abdomen are encased in a plaster cast. In such 
cases the sitting posture should be avoided. The infants are kept in 
the arms or sleep on an ordinary hair mattress without a pillow. It 
is not possible to keep them in any particular posture. Massage of 
the spine is of questionable utility. 

Operations for the correction of deformities of the long bones 
should not be carried out until the rachitic process has conic to a 
standstill. Surgeons sometimes advise the correction o\ deformities 
in young infants by encasing the limbs in plaster while the bones 
are still soft. 



250 DISEASES DUE TO DISTURBANCES OF NUTRITION. 

CHONDRODYSTROPHIA FCETALIS. 

(So-called Foetal Rickets; Achondroplasia, Micromelia.) 

Definition. — This is a true dystrophia of cartilaginous growth in 
the long hones, resulting in deformities which consist in a shortening 
of the extremities and certain changes in the bony structure of the 
head. Cases of this rare condition have been reported in this country 
by Jacobi, Smith, Herrman, and Townsend. Thomson, of Edin- 
burgh, has described the affection as of intra-uterine origin. Although 
Horsley and Barlow classify these cases with sporadic cretinism, they 
have nothing in common either with cretinism or rachitis, and must 
be regarded as a distinct pathological entity. The patients are far 
from being idiotic or presenting any of the symptoms of myxoedema. 
The case published by Townsend was that of a still-born infant. 
Parrot and Jacobi have described infantile cases. 

Forms. — From a pathological standpoint there are three forms of 
this affection: The first is that in which there is a softening of the 
primordial cartilage, or so-called chondromalacia foetalis ; second, that 
in which there is a cessation of growth of cartilage, so-called chondro- 
dystrophia hypoplastica ; and lastly, the form in which there is an 
increased but very irregular growth of the cartilaginous part of the 
long bones, so-called chondrodystrophia hyperplastica. In all of these 
forms the resulting deformities are characteristic. They are as 
follows : 

(a) The skull has a peculiar form, the vertex is large. The root 
of the nose in one set of cases is sunken; in another set the whole 
nose is flattened. In both sets of cases a peculiar expression is given 
to the face, which at first was mistaken for cretinoid. The form of 
the skull was thought by Virchow to be due to a premature synostosis 
of the three bones comprising the tribasilar bone ; this has since been 
disproved, being true of only one set of cases ; in some cases the whole 
tribasilar bone is cartilaginous, and in others there is no synchondro- 
sis, nor even a marked shortening or premature synchondrosis. The 
changes in the skull are of the same nature as those in the long bones, 
viz., dystrophic. 

(b) The long bones in the most characteristic types are shortened. 
The diaphysis is short and thick, so as to present little or no medul- 
lary canal ; the epiphyses are mostly cartilaginous and enlarged, and 
the whole bone is bent, the normal curve being exaggerated. The 
picture thus presented is that of a dwarf with short extremities 
(micromelia). There are forms of chondrodystrophia without any 
marked shortening of the extremities, but rather of the lower part 
of the trunk (Klebs, Kaufmann). 

Morbid Anatomy. — There are no changes in any of the internal 



PLATE XI 





Chondrodystrophia Foetalis, or Achondroplasia. 



A— Infant, aged nine months. 
B — Child, aged three years. 



CHONDRODYSTROPHY FETALIS. 251 

organs. The parts at the base of the brain, the pons, may extend 
above the sella turcica in an upward instead of a forward direction. 
This is due to the peculiar changes present at the base of the skull. 
The pituitary body is normal. The thyroid shows no marked changes. 
The flat bones are normal ; but in the bones which are formed from 
cartilage, the so-called endochondral ossification is disturbed. These 
bones, such as the sternum, patella, and costal cartilages, the tarsal 
and metacarpal bones, show changes. The long bones present endo- 
chondral disturbances; there is an absence of the long lines of car- 
tilaginous cells, and at the ossification zone there is a most irregular 
proliferation of cartilage-cells and ossification. It is thus that the 
growth of the long bones, of the innominata, and of the bones at the 
base of the skull are disturbed. The vertebral column may be 
normal, or the antero-posterior diameter of the vertebrae may be 
shortened. The thorax is small and flat, due to arrested development 
of the ribs. On section the bones present no parallel rows of cartilage- 
cells, no medullary spaces, no projection of medullary bloodvessels 
into the cartilage. There is an absence of vessels at the ossifying 
junction, the bone being formed mainly from the periosteum. The 
heads of the bones are thus chiefly made up of hyaline cartilage ; the 
shaft of the bone of periosteal bone-formation. 

From the above data of the morbid anatomy in this disease it 
can be seen why this condition has nothing in common with rachitis 
and cretinism, and should not be called foetal rickets or " so-called " 
foetal rachitis. 

Symptoms. — The general picture is that of a dwarf with short 
extremities and a body trunk of normal length. The four extremi- 
ties are affected. The arms are shorter than the forearms, the thighs 
than the legs. The head is large, at times assuming a hydroceph- 
alic contour, the parietal and frontal bones are prominent, the root 
of the nose is broad, the bridge depressed, the tip large and the nos- 
trils open, the features are large and heavy. The vault of the palate 
is high. The lumbar curve of the spine forward is much exagger- 
ated, the sacrum thrown back, causing in the female a narrowing of 
the brim. The hips are large and muscular, as also the muscles of 
the extremities and trunk. The lower extremities are bowed and 
the legs are articulated at an angle with the thigh. The hands are 
square, massive, reduced in all proportions, the ringers oi' equal 
length, thus giving, when spread, the appearance oi' a trident. The 
intelligence is very good ; in some cases the subjects may not be as 
bright as the normal individuals. 

Diagnosis.- A differential diagnosis must be made from Rachitis, 
Cretinism, Infantilism, and Osteogenesis imperfecta, A careful 
study of the symptomatology will show quite distinctly that the 



252 DISEASES DUE TO DISTURBANCES OF NUTRITION. 

characteristics of each of these conditions cannot be mistaken for 
each other. 

Prognosis and History. — Many of these cases die at birth, but 
many attain adult life and are of good intelligence, though some cases 
may have less than the normal intelligence. They may have children. 
The children of the female sex may have chondrodystrophy ; though 
among the handsomest that I have ever seen were the offspring of a 
female chondrodystrophy dwarf, whose children were patients in my 
clinic. This dwarf had little difficulty in labor, though in some cases 
this difficulty may be present. Her children presented absolutely no 
deformities, but were brought for treatment for the slight disturb- 
ances of infancy and childhood. 

OSTEOGENESIS IMPERFECTA. 

(Fragilitas Ossium Idiopathica.) 

This is a systemic disease of the bones which attacks the young 
foetus, and, without causing appreciable abnormalities in other organs, 
prevents or disturbs the normal development and calcification of osteoid 
tissue. The disease manifests itself by defective development of the 
cranial bones, with fragility of the entire osseous skeleton. Cases of 
this nature have been reported in the foetus or in the newborn infant — 
born dead or dying within a short time after birth; recently, how- 
ever, cases have appeared in the literature which have lived to adoles- 
cence with all the symptoms of the affection. 

Morbid Anatomy. — The examination of the bones after their re- 
moval from the body shows them to be delicate and fragile, fracturing 
with the slightest force. At times the periosteal bone shell is so 
thin that it may be crushed between the fingers with very little force.. 
Sections of the bones show them to be porous, the trabecule delicate, 
the outer layer exceedingly thin, there being no dense bone, but a 
collection of small plates and trabecular Calcification of the osteoid 
tissue is defective or entirely absent in places. The epiphyseal car- 
tilages are normal, both in size and consistence. Microscopically, it 
is revealed that the process is confined entirely to the shaft of the 
bone, where the normal development and calcification of osteoid tissue 
is lacking. The formation of rows and their subsequent calcification 
and disintegration go on in a normal manner. It is at the stage of 
true bone-formation that the disease is manifest. The osteoblasts are 
diminished in numbers and deposit only a thin layer of osseous tissue. 
Calcification is thus delayed, deficient, or entirely absent. The 
other organs of the body are entirely normal. 

Symptoms. — The general appearance of the newborn infant with 
osteogenesis imperfecta is characteristic. The skin and the subcu- 



OSTEOGENESIS FCETALIS. 253 

taneous tissue may be thickened; on the other hand, they may be 
quite normal. The extremities are not shortened as the result of the 
cessation or retardation of growth, but are bent and deformed and 
may be the seat of multiple fractures. The ribs may be the seat of 
fracture. Some of these fractures may have united in utero, in 
which event we have the resulting deformity. Fractures may be so 
numerous as to give the long bones a nodular appearance. All the 
bones of the body partake of this fragility. The spinal column is 
soft and fragile, presenting anteroposterior and lateral deviation-. 
The ribs may be fractured to an excessive degree. In Merkel's case 
no less than forty-three fractures were present. The clavicle shows 
fractures very similar to what is seen in cases of rachitis. The 
cranial bones show defective ossification, as is evidenced by the widely 
open sutures, or the cranial vault may consist simply of a mem- 
branous sac. 

The slightest traumatism, such as a jar against some object, may 
produce these fractures. They occur soon after birth and may be 
present, though unsuspected, when the child is born. When born, 
children are carefully handled, for which reason fractures are not so 
likely to be observed at this time ; as soon, however, as the children are 
allowed more liberty of motion fractures occur. They are attended 
with less pain and inflammation than in the normal individual, due, 
no doubt, to the slight traumatism. Union takes place rapidly and is 
usually firm. In some cases complete fracture does not occur, but 
infraction, resembling in a general way what is seen in rachitis. 
Some individuals not only survive childhood and learn to walk but 
may attain adolescence suffering from this disease. 

Differential Diagnosis. — Differential diagnosis must be made from 
chondrodystrophia foetalis. In the latter disease the prognathous 
expression of the face is characteristic, with flattening of the nasal 
region; the bones, though shortened, are dense and hard, and, aside 
from slight bowing of the legs, are not deformed. In later life the 
chondrodystrophic individual is a dwarf, with shortened exrremitit s 
and no predisposition of the bones to fracture. 

Osteogenesis imperfecta is differentiated from rachitis by the ab- 
sence of the rib rosary, the enlarged epiphyses, and other states char- 
acteristic of the disease. We can scarcely confound this disease with 
hereditary syphilis, or sarcoma or any new growth of the bone, or 
osteomyelitis. The dystrophy of syphilis is so characteristic as to 
bear no resemblance to the disease just described, the chief charac- 
teristics of which are fragility o( the bones associated with defective 
ossification of the cranial bones. 

Etiology.- The etiology of" this disease is as ye1 a matter o( 
speculation. 



254 DISEASES DUE TO DISTURBANCES OF NUTRITION. 

Treatment. — Its treatment must be founded on general indications, 
increasing the strength of the patient and protecting the bones from 
fracture. 

INFANTILE SCORBUTUS OR SCURVY (Barlow). 

(Acute Rachitis (Moller) ; Barlow's Disease, Hemorrhagic Rachitis (Furst) ; 
Scurvy Rickets (Cheadle) ; Hemorrhagic Periostitis (Smith).) 

History. — Cases of this affection are described in the early litera- 
ture under the name Acute Rachitis, given to it by Moller, 1859— 
1862. The first definite clinical description of the disease under its 
present title was made by Barlow. Cheadle, Gee, and others of the 
English school, completed its clinical study, iNorthrup and Crandall 
have made it familiar to American physicians. 

Occurrence. — The disease occurs chiefly in infants and in chil- 
dren under the age of two years. Under certain conditions it also 
occurs in older children and in adults. The majority of the 372 
cases collected by the committee of the American Pediatric Society, 
occurred between the sixth and fourteenth months. The ninth month 
showed the greatest percentage of the cases occurring before the end 
of the second year. The sexes were equally affected. A second 
attack was recorded in a case of Holt's. In one of my cases there 
were two attacks. 

The Nature of the Affection. — The nature of scurvy as it is seen 
in infants and children is still obscure. It is undoubtedly a form of 
hemorrhagic diathesis, which attacks subjects susceptible because of 
previous abnormal constitutional conditions and defective nutrition. 
There are several theories as to its exact nature. Xone is universally 
accepted. Some insist that it is a form of acute rachitis (Moller, 
Forster, Bohm, Steiner, Fiirst, Ausset). Others contend that it is a 
form of scorbutus (Barlow, Northrup, Crandall, better, Rehn, Pott). 
Some of the English school regard it as a combination of scurvy and 
rickets (Cheadle, Gee, West). To the latter contention Heubner, 
Schoedel, and Xauwerck give most support. These authors insist 
that the disease supervenes only in an organism already affected by 
slight or marked rachitis. On the other hand, Schmorl and JSTaegeli 
think that the affection is sui generis. Some have endeavored to 
establish a correlation with congenital syphilis. The consensus of 
clinical opinion, however, tends toward the acceptance of the theory 
of the scorbutic nature of the affection and its close connection with 
disturbances of nutrition. 

Etiology. — The essential exciting cause is not yet known. The 
theory of the toxsemic or infectious nature of the disease has been 
advocated by William Koch. Bacteria of various kinds have been 



INFANTILE SCORBUTUS OB SCURVY. 255 

found in the blood, but there is little uniformity in the results of these 
studies. In all the cases thus far studied the nature of the diet. 
breast-milk, raw cows' milk, sterilized or pasteurized milk, or some 
artificial food, has been a strong predisposing factor. The diet has 
been insufficient for the nutrition of the patient, but what special 
element has been lacking in the food is still obscure. In the collected 
results of the investigations of the American Pediatric Society 10 
infants were wholly breast-fed ; 2 were partially breast-fed ; 4 took 
raw milk. The greater number, 68, were brought up exclusively on 
sterilized milk; 16 took Pasteurized milk. The others took foods of 
different kinds. It may be that the mode of preparing the food 
(raw cows' milk, Pasteurized or sterilized milk) is of less importance 
in paving the way for the onset of this affection than its inherent 
composition. Cases have been cured in part by changing the compo- 
sition of the food, also by substituting sterilized for pasteurized food, 
and vice versa. The very fact that breast-milk has been the exclusive 
article of diet in some cases should direct attention to the fact that 
the affection may be caused by lack of some necessary element in the 
food. This view is commonly accepted at present. 

It is interesting in this connection to consider the contention of 
the celebrated Arctic explorer Hansen, that with exercise and fresh 
air, and abstinence from alcohol, scurvy on voyages will be unknown 
if foods are carefully sterilized and devoid of toxins and ptomains. 
The latter, he insists, exist in most of the milk, fish, and food eaten 
on voyages. Although in the most aggravated cases of scurvy that 
have come under my notice the diet has been sterilized milk, many 
infants who take that food prepared properly do not develop the dis- 
ease. Some authors believe that the success of antiscorbutic treat- 
ment with vegetable acids indicates that the organism has been for a 
time deprived of some essential food element. In the presence of a 
concrete case attention should first be directed to securing fresh food 
of proper composition. 

In one of my cases a good raw milk was the food, but it contained 
7 per cent, of fat. In another case the infant was at the breast, the 
milk of which contained only .7 per cent, of fat; both of these foods 
on the face of it were deiiutritional. 

Rachitis. — -Much has been said as to the connection of rachitis 
with this disease. The investigations above referred To show rhar 
fully 45 per cent, of the cases occurred in infants and children who 
showed clinically signs of rachitis. This does not account for ease- 
in which rachitis may exisl, but may not be apparent except on 
microscopic examination (Hirschsprung, Schoedel). The majority 
of cases examined post mortem showed the changes of rachitis 
(Schoedel, SehniorlV 



256 DISEASES DUE TO DISTURBANCES OF NUTRITION. 

Morbid Anatomy. — The morbid anatomy has been carefully and 
extensively studied by Schoedel, Nauwerck, and Schmorl, whose re- 
sults agree in all essentials. 

Bones. — The bones in most cases show the changes seen in rachitis. 
There are disturbances of growth and of bone formation. There is 
an increase in the width and vascularization of the cartilage zone. 
There are irregularity of the calcification zone, and a pathological 
formation of osteoid tissue. The changes at the epiphyseal junction 
and the periosteum are those seen in rachitis. The ribs are the bones 
most frequently affected, the next greatest frequency being in the 
bones of the lower and upper extremities. The changes caused by 
scurvy consist of hemorrhages into the loose vascular layer of con- 
nective tissue of the periosteum adjacent to the bone. Thus the 
hemorrhages are intraperiosteal and subperiosteal (Plate XII.). 
They may be of considerable extent, either in the vicinity of the 
epiphyseal junction or in course of the shaft of the bone. They may 
form a layer several millimetres or centimetres in thickness. The 
outer layer of the periosteum, the fibrillar connective-tissue strata, is 
not the seat of hemorrhage except in the severest cases. The layer 
of periosteum next the bone is thickened. The hemorrhages are both 
recent and old. Hemorrhages of both kinds are found in the medul- 
lary canal. The morbid changes are most marked in the ribs, next in 
the femur and in the bones of the upper extremities. Some of the 
long bones show loosening and even separation of the epiphyses and 
diaphyses. The infractures or fractures are of this nature. The 
fragments may override. In such cases the hemorrhage is great. 
The marrow of the bones loses its lymphoid character and becomes 
gelatinous. 

There are subpleural and subepicardial hemorrhages. The spleen 
is enlarged, owing to the presence of rachitis. Slight subcutaneous 
hemorrhages may extend into the muscular tissue. There are hemor- 
rhages into the mucous membrane of the hard palate and gums. 

Symptoms. — Mild cases sometimes escape notice. An anaemic 
infant may cry when bathed or may favor one extremity. It may 
hold one thigh rigid or cry when the limb is handled in the process 
of diapering. Mothers at first suspect traumatism. The infant 
develops slight ecchymoses on the tibiae, and is then brought to the 
physician. If there are teeth, there may at this stage be no swelling 
of the gums or of the extremities. Along the border of the gums 
there is a very thin blue line. There is no fever ; there may not be 
any anaemia. In some of my very early cases, in addition to tender- 
ness of the bones, there was hematuria. In the severer cases the 
symptoms are more marked. The skin in the infant of from seven 
to nine months of age acquires a pallid or greenish tinge. The infant 
cries when touched. 



PLATE XII 




X-ray of the Bones of the Leg in a Case of Scorbutus, 

showing the hemorrhage under and in the periosteum of 
the tibia at the junction of the middle and lower third of 
the bone. 






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INFANTILE SCORBUTUS OR SCURFY. 257 

Xhie or both of the lower extremities lies as if paralyzed. If an 
attempt is made to move them, the infant appears to feel pain. The 
limb is swollen in the course of the shaft or in the vicinity of the 
knee or ankle, the swelling extending up the shaft (Plate XIII. j. 
The ribs are apparently tender. There may be one or two subcu- 
taneous ecchymoses on the surface of the body. If there are teeth, 
the gums, especially those of the upper jaw, are swollen into cushion- 
like formations. These bleed easily and may partly conceal the teeth. 
If there are no teeth, the gums may appear normal, or the free bor- 
der, especially of those of the upper jaw, may have a bluish, swollen 
appearance, which may be very slight or quite marked. There may 
be a small hemorrhage into the sac of the tooth which may not yet 
have erupted. The infants may have a capricious appetite, may take 
little of the bottle or may nurse ravenously. 

The very severe cases have, as a rule, been allowed to run on for 
months in the belief that the infants were suffering either from rheu- 
matism or dropsy. For some time before coming under treatment, 
the infant has cried when diapered or when the shoes or stockings 
were put on ; later it becomes pale and loses ground. The appetite 
is poor. The thighs and the ankles begin to swell. The child does 
not move the extremities, which are swollen to twice or three times 
the original circumference. Ecchymoses appear on the surface of 
the swellings of the legs and thighs. Parts of the skin acquire a 
bluish-green, bruised appearance. Deformity occurs in the thigh, 
especially at the junction of the diaphysis with the head of the bones. 
This is due to infracture or loosening of the epiphyses at the epiphy- 
seal line. The costochondral junction of the ribs is much swollen. 
There is a distinct series of very large swellings in this locality which 
are due to hemorrhage into the line of juncture of the rib and carti- 
lage. Ecchymoses and sugillation appear about the orbit. The face 
and eyes have an (Edematous, hydrsemic appearance. The gums may 
not be at all affected, but if the infant has teeth there may be spongi- 
ness and bluish discoloration of the gums. 

When the infant is examined, the pain produced by the procedure 
causes it to shriek with agony. The ribs are painful to the touch. 
The swellings on the thigh are uniformly fusiform, and, as a rule, 
hard and not fluctuating. The abdomen is tense and tympanitic. 
There may be some bleeding from the nose, but not necessarily from 
the bowel. In other cases there are not only hemorrhages from the 
bowels, but also from the kidney, in the form of hematuria. There 
nmy be albumin and casts in the urine, or these may be absent. 

Of especial interesl are those cases in which hsematuria is the 
only marked objective symptom of the disease. Such eases as 1 have 
seen were in excellent physical condition, of good weighl and color, 

17 



258 



DISEASES DUE TO DISTURBANCES OF NUTRITION. 



and still for a period of days or weeks have voided urine which con- 
tains blood, but no casts. Careful examination will reveal a tender- 
ness of the tibiae, or a just perceivable swelling of the gums or a very 
narrow blue line along the gums. I have recently seen a number of 
cases of scorbutus in which the main symptom was the appearance of 
blood in the stools, simulating a dysentery. In another case, that of 
a child twenty-two months of age, the first symptom of scorbutus was 
a sharp hemorrhage from the bowel. This hemorrhage was repeated, 
but was not as profuse as the initial one. A careful examination in 
this case revealed a slight tenderness of the tibise and a tendency to 
ecchymoses following the least traumatism. 

















































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Temperature-curve of a case of scorbutus in an infant seven months of age. Resorp- 
tion fever. The chart shows the very high number of respirations as compared to the 
pulse. Cause of high respirations probably pain and extreme anaemia. The curve taken 
from the start of treatment. 



The pulse is, as a rule, not increased in frequency. In one case 
without complicating pneumonia, in which I found the respirations 
enormously increased, I reached the conclusion that this increase was 
due to the pain and extreme anaemia. 

In severe cases there may be slight temperature (Fig. 33), due to 
resorptive fever caused by the immense extravasations of blood. 

The hemorrhages in the skin may be localized in the form of 
minute petechias or there may be ecchymotic blotches of considerable 
size. The latter may appear over the swellings along the bones. 

The fractures or infractions were present in only 9 cases of the 
set collected by the American Pediatric Society. The gums were 
generally affected in infants with teeth, and were swollen and spongy 
in 24 cases in which there were no teeth. They may be normal in 
severe cases if there were no teeth, and swollen in mild ones. The 
symptoms in older children resemble those of adults. In one case 
in a child over two years of age the surgeons of a dental clinic had 



INFANTILE SCORBUTUS OH SCURVY. 259 

been consulted for an uncontrollable bleeding of the gums. The 
child had ceased to walk on account of pains in the lower extremities, 
which had been interpreted as rheumatic. In older children the 
gums are affected, and the hemorrhages take the form of petechia 
and blotches, appearing in crops over the surface of the body as in 
the adult. They have joint-pains and malaise. 

Prognosis. — The disease in infants and children gives a very good 
prognosis if recognized and treated in time. Most cases recover. 
The fatal cases are those in institutions or elsewhere in which the 
diagnosis has not been made or in which death has been caused by 
some intercurrent affection, such as cerebral hemorrhage, diarrhoea, 
or pneumonia. In 379 cases collected by the American Pediatric 
Society the mortality was 8 per cent. It would seem to-day that with 
improved methods this figure should be much lower. 

Duration. — There is no fixed duration. Much depends on an 
early diagnosis. Even if the disease has existed months before a 
diagnosis is made, the patient may still recover. The great danger 
is that a hemorrhage may occur in the cerebrum or that the infant 
may contract an intercurrent affection through exhaustion. If allowed 
to continue without treatment, the disease may cause exhausting intes- 
tinal hemorrhages or hemorrhage of great extent elsewhere, with con- 
sequent anaemia and death. 

Diagnosis. — The diagnosis of infantile scurvy presents no difficul- 
ties. The pains in the extremities, the paralytic phenomena, the 
swelling of the gums, the swelling in the vicinity of the joints of the 
limbs or along the shafts of the bones, the swellings on the ribs, and 
the ecchymoses in the skin and about the eye, are all characteristic. 
The pareses of the upper extremity are frequently mistaken for those 
due to syphilis. The history, and the absence of syphilitic eruptions 
will aid in diagnosis. In the presence of a hematuria in an artifi- 
cially-fed infant, where other causal elements fail we should always 
think of the possibility of scurvy. In cases of prolonged enteric 
catarrh, in which the infants are emaciated and pass pure blood with 
the movements, scurvy should be thought of. I have seen a case of 
scurvy with hemorrhages from the bowel mistaken for intussuscep- 
tion, and operated under this mistaken diagnosis. 

Treatment. — The treatment of infantile scurvy is simple and sat- 
isfactory. The infant is given fresh milk properly modified. The 
milk should be given raw, and in summer should be kept well packed 
in ice. In addition, orange-juice and lemonade are given in the 
course of the day. An infant seven months old should have 2 ounces 
of lemonade and one ounce of orange-juice in twenty-four hours, given 
every two hours after each nursing. Some authors advise the giving 
of beef-juice, but it is necessary only when fruit juices are not toler- 



260 DISEASES DUE TO DISTURBANCES OF NUTRITION. 

ated. After two weeks the quantity of fruit juice should be reduced, 
but a small quantity of orange-juice should be given daily for some 
time. Medicines are not indicated except for the anaemia, which is 
best treated by doses of half a drop of Fowler's solution given three 
times daily, or by some easily assimilable peptonate of iron. 

MARASMUS OR INFANTILE ATROPHY. 

(Athrepsia (Parrot).) 

Definition. — Infantile atrophy or marasmus is a condition due to a 
distinct disturbance of nutrition traceable to the food of the infant in 
the absence of any infectious or bacterial agent. 

Occurrence.- — It is seen in infants both of the wealthy class and 
among the poor. In both cases the infants have been improperly 
fed and in breast-fed infants the same results follow as in bottle-fed 
infants if the breast-milk is inefficient. Secondarily it may follow 
any disease of the gut or complicate syphilis or prematurity, but these 
cases are not properly included under the heading of primary atrophy. 

Etiology. — The cause of atrophy is now quite well understood. It 
is not the result of any infection but is the cumulative result of the 
inefficiency of the food in sustaining the nutrition. The elements of 
the food to which in past years most attention and study have been 
directed, especially in bottle-fed infants, are the fats, proteids, and 
carbohydrates or sugar. Formerly the proteids of cows' milk were 
thought to work great injury to the infant and those who did not 
thrive and finally developed the symptom complex of atrophy were 
thought to have fallen victims to the great difficulty of assimilation 
of the proteids. The casein of cows' milk, it was argued, coagulated 
in the stomach in thick leathery curds and the energy expended by 
the stomach and intestine in assimilating and especially preparing 
these curds for assimilation wore out the infant and appropriated 
energy to the loss of body-weight. 

Heubner and Rubner especially were active in maintaining this 
theory. To-day we are not so certain that this is really so or that 
the casein of cows' milk is so much more difficult of digestion than 
that of mother's milk. Some maintain (Meyer) that the difficulty 
lies, not in the rough curding of the casein of cows' milk, but in the 
inability of some infants to convert the foreign proteid of cows' milk 
into a proteid which is similar to that of breast-milk and therefore 
ready for assimilation. Rotch, Holt, and others still maintain that 
the difficulty is in the way of complete assimilation of the casein of 
cows' milk, while, on the other hand, Jacobi, Escherich, Czerny hold 
other elements of the milk responsible for the difficult assimilation of 
cows' milk. Czerny goes so far as to challenge any evidence as to 



MARASMUS OR INFANTILE ATROPHY. 261 

the fact that casein of cows' milk is difficult of digestion even by the 
youngest infant. 

The Fats.— Jacobi was among the first to point out that the fats 
of cows' milk were the main difficulty in the complete assimilation of 
cows' milk and still maintains that malnutrition is brought about in 
some infants by too great fat percentages. Czerny has for years 
gradually worked out methods of feeding which are based on the con- 
viction that the fats in the cows' milk are exceedingly noxious to some 
infants. Czerny and Keller have shown that the fats cause excessive 
production of acids in the intestine, an acidosis. In these disturbed 
conditions of nutrition, resulting in atrophy, ammonia in large 
amounts is excreted in the urine instead of urea. The formation of 
ammonia entails a drain on the economy, hence the emaciation. 
Excess of fats in the food favors the production and over-production 
of acids in the gut. There is no question of infection for the condi- 
tions above are produced in the face of utmost cleanliness and a germ- 
free or practically bacterial-free food. 

Cereals and Carbohydrates. — As to the injury done to infants by 
cereals and carbohydrates as an exclusive diet, there can be but one 
opinion. The newborn infants, though they bear cereals, as barley, 
well when combined in dilute solutions with milk, do not bear them 
well, exclusively. This is seen in many cases of marasmus in which 
the infants from the start were fed on some infant food which in the 
main was a refined cereal or a cereal combined with some form of 
sugar. Such foods seem to agree with the infants at first, but after 
a while they develop symptoms which become cumulative and result 
in injury to the infant nutrition. Condensed milk, made up largely 
of carbohydrate or that with a low proteid, tends to bring about 
the symptoms which show a severe disturbance of nutrition. 

Morbid Anatomy. — It must be kept in mind that whatever is found 
post mortem in the form of an infection is an after-effect of the 
reduced physical condition of the infant and is secondary to the main 
condition which is one of progressive failure of nutrition. 

The body is much emaciated ; the skin hangs in folds on the 
extremities, and presents hemorrhages or petechias. The lungs may 
show atelectatic areas or may be the seat of bronchopneumonia. The 
heart is small and the muscle-fibre pale. In many eases the stomach 
is dilated and the mucous membrane pale. The small intestine shows 
few changes. The Peycr's patches may be slightly raised and show 
the so-called shaven-beard appearance. The follicles of the colon 
may be slightly prominent. The microscopical changes in the gut 
are not characteristic. In some places the follicles an 1 the seal oi 
catarrhal inflammation. Both in the stomach and the intestines there 
are patches where there is an absence of glandular tissue: in its place 



262 



DISEASES DUE TO DISTURBANCES OF NUTRITION. 



Fig. 34. 



is a newly formed connective tissue composed of round and spindle- 
shaped cells. The villi of the gut have disappeared. The whole 
mucosa is thinner than is normal (Baginsky). On the other hand, 
these changes may not be marked. / 

Heubner thinks that these changes in the gut described by Ba- 
ginsky are postmortem artifacts and are not the result of the disease. 
The liver is fatty and may be enlarged. The spleen is small. The 
kidneys may be pale, especially in the cortex, and may be the seat 
of parenchymatous degeneration. The lymph-nodes of the mesentery 
may be enlarged. 

Symptoms.- — The symptoms of infantile atrophy are rather cumu- 
lative and begin to show themselves after a time of feeding which 
may not have been so discouraging at first. The infant may have 
been premature or of fine normal development at birth. Whether 

on the breast or bottle the signs 
of disturbance are much the 
same. They begin with slight 
marks of trouble. The color 
of the infant fails at first ; 
there are slight dyspeptic dis- 
turbances, such as spitting up, 
or colic and restlessness; and 
then the first serious sign that 
inroads are being made on the 
economy is met with in the 
stationary weight. With the 
occurrence of this stationary 
weight, the stools are either 
constipated, dry and soapy in 
consistency, or they may be 
soft and curdy. The infants 
cry incessantly and have a 
ravenous appetite which is not 
appeased by more food. The 
greater amount of food which 
is given under the mistaken idea that they are hungry does not 
nourish the infants and added to the serious symptom of stationary 
weight we finally have loss of weight. 

The condition is now progressive. The muscles and tissues lose 
their physiological tone, the fat disappears and the skin hangs loose 
on the extremities, the face is thin and the infant has an old, senile 
appearance, the chest is emaciated, the ribs show, and the fonta- 
nelles are depressed. Over the buccinator muscle is a small cushion 
of fat, the so-called " sucking pads," which persist when all other 




Vertical section of the head of a child 
two months of age, showing the sucking pads 
(S. C). Symington. 



MARASMUS OR INFANTILE ATROPHY. 263 

facial fat has disappeared. This gives the cheeks a peculiarly puffed 
look. At this stage infections are apt to add to the seriousness of 
the situation. Furuncles, intertrigo of the buttocks, erosions of all 
kinds, or sprue, are apt to make their appearance favored by the least 
neglect. The buttocks are much emaciated and the tuber ischii show 
prominently. The heart is weak and in the last stages the muscular 
sound is scarcely audible. The patients become an easy prey to 
gastro-intestinal infection with resultant diarrhoea which may close 
the scene. The temperature if no infection be present may be normal 
or subnormal. The infants in many cases finally lose all desire for 
food. Others drink with avidity, but do not assimilate the food 
taken. If untreated, these infants emaciate until they are reduced 
to skin and bones. They grow exceedingly weak, and die with some 
intercurrent infection, such as pneumonia, tuberculosis, or infectious 
disease. 

Treatment. — In the treatment of infantile atrophy lie all the 
problems which have confronted the physician in infant feeding. If 
the student or practitioner desires to attain great success he must 
approach each individual case and study what element in the feed- 
ing is at fault. As a rule he well find that the infant has been fed 
haphazard or with frequent changes of formulae without any par- 
ticular direction, or that there has been a too continued effort to make 
the infant's digestion conform to a food in the face of bad results; 
or that the infant has been fed on some infant food. If the infant 
has been fed on cows' milk, either the quantity has been too great in 
the aggregate or the quality too strong as it is called. If the infant 
has been receiving too concentrated a mixture, the first step is dilu- 
tion. In mild cases this alone will work quite well. Too great a 
dilution is not effective, however, because if the fat is at fault and 
the milk is diluted too much, the proteids are reduced. Even if we 
finally find a mixture which affords certain relief to the symptoms, 
the infant does not increase in weight because something is lacking. 
In such cases the addition of cereal will solve the difficulty and an 
increase of weight will result. Quite often this is ineffective so that 
in addition to the cereal some carbohydrate, such as the malted foods, 
must be added. In such cases Keller has devised a modification of 
the old Liebig formula by which the cereal and malted sugar are 
added to the milk. He has called this malt soup. 

In other cases we find that where fats are not borne well the 
butter milk described elsewhere has given excellent results because it 
is a fat-free food rich in proteids containing also a cereal and carbo- 
hydrate (cane-sugar). As it is still difficult to obtain a reliable 
butter milk and an account of the great danger au ending the use of 
some of its forms, this method of feeding atrophic infants has been 
abandoned for the present. 



264 DISEASES DUE TO DISTURBANCES OF NUTRITION, 

It will thus be seen that the management of these cases presup- 
poses study of the needs of each particular individual. If the first 
few attempts to feed such infants do not result in palpable progress 
there should be no dangerous delay and experimentation, but the 
infants should be given the human breast as soon as possible. JSo 
infant is too old to place at the breast. With patience and care most 
infants, even if past the first period of infancy, may be taught to 
take the breast. The result at first is sometimes discouraging, as 
the increase in weight is not always commensurate with the expecta- 
tion, but when it once begins it is nothing short of marvellous how 
an infant reduced to skin and bones will in a short time fully double 
its weight. 

With the feeding, the general hygiene of the infant should receive 
attention. Daily baths with sea-salt and open-air life are especially 
indicated. 

In infantile atrophy the medical and mechanical treatment are of 
less importance than the selection of proper food. For this reason 
we should not seek to multiply remedies. The movements of the 
bowels in some cases have an exceedingly fetid odor. The treatment 
is begun with the administration of brisk cathartics, such as castor 
oil. The bowel is then washed out once a day until the character of 
the movements has improved. If there is a tendency to diarrhoea, 
tannigen, with or without bismuth, may be given three or four times 
daily. If there is any great amount of gas generated in the stomach, 
a very small dose of dilute hydrochloric acid and pepsin should be 
given daily after a feeding. 



SECTION V. 

THE SPECIFIC INFECTIOUS DISEASES. 

THE EXANTHEMATA. 

The exanthemata, scarlet fever, measles, Rotheln, varicella, and 
variola, are acute specific infectious diseases, characterized by an 
eruption on the skin, the so-called exanthema or rash. They form a 
distinct group. The poison or infectious element originates in the 
body of the patient. The nature of this poison is unknown. Though 
suspected to be bacterial, the essential cause in any of the exanthemata 
has not been isolated. We do know, however, that the acute exan- 
themata are conveyed from one person to another by direct contact or 
through the medium of the atmosphere. In this respect they differ 
essentially from such diseases as typhoid fever, or even syphilis, in 
which the morbific agent must be introduced into the body. They 
are therefore not only communicable but contagious in the true sense 
of the term. Most people are susceptible to some of the exanthemata, 
such as measles and smallpox. On the other hand, not every one 
exposed to contagion will contract scarlet fever or varicella. Few 
persons are attacked twice by the same exanthematic affection, but 
there are exceptions to this rule. An attack of one disease, such as 
measles, does not confer immunity from an attack of another, such as 
scarlet fever. 

The exanthemata occur either endemically or epidemically. Each 
has a well-defined period of incubation — that is to say, an interval 
between the time of the exposure to contagion and the onset of char- 
acteristic symptoms. In the different exanthemata this interval 
varies within wide limits. The period of incubation seems to be 
more accurately determined in measles than in the other exanthemata. 
It is well established that two of the exanthemata may occur at the 
same time in the same subject. This is not a point in favor of the 
identity of the essential cause of the exanthemata. On the contrary, 
it is an accepted fact that each of the exanthemata is distinct in itself, 
and that each disease has its specific essential cause. 

SCARLET FEVER. 

Scarlet fever is an acute infectious disease with a characteristic 
rash or exanthema, ll is highly contagious. 

Etiology. -■ 1 1 has no1 as ye1 been established whether the infec- 

265 



266 THE SPECIFIC INFECTIOUS DISEASES. 

tious agent is a micro-organism, although streptococci have been 
isolated from the secretions and scales in the desquamative period. 
Neither do we know whether there is an organism, a protozoan, in 
the circulating blood. Mallory, Duval and Field have described cer- 
tain protozoa-like bodies in the lymph-spaces of the skin. Field 
regards them as being derived from the protoplasm of degenerated 
epithelial cells. 

The atmosphere about the patient seems in most cases to be the 
zone of contagion. The nearer a person has been to the patient the 
more likely is he to convey the disease to a third person. Articles of 
clothing may retain the infection for months. Scales from the skin 
of the patient, dried secretions, the urine if nephritis exists, and fasces 
are also mediums of infection. The longer the physician remains 
near the patient the more likely is he to convey the disease. This 
mode of infection occurs. Osier records his belief in having carried 
infection to a patient. Foodstuffs handled by those suffering from 
the disease or by those who have been near patients may convey the 
disease. This is especially the case with milk, which is said to have 
been the cause of epidemics in England. The poison of scarlet fever 
seems to pervade the ward or sick-room for a long time. Whether 
this period extends over two years, as recorded by Murchison, is a 
matter not yet settled. "We do not yet know how the poison obtains 
entrance to the body. The discharge from a scarlatinal otitis is said 
to be capable of communicating the disease. 

Susceptibility. — All children exposed to infection do not contract 
the disease. It is less contagious than measles. On the other hand, 
although a person may be exposed once and escape, he is not neces- 
sarily immune to future exposures. A nurse attended many cases 
for me before contracting the disease. As a rule, one attack of scarlet 
fever protects a person from subsequent attacks. The literature 
records cases of well-observed second and third attacks. The author 
has seen cases of a second attack. We should, however, be cautious 
in accepting reports of repeated attacks. Eotheln may have been 
mistaken for scarlet fever. 

Occurrence. — Scarlet fever occurs at any age, and in all countries, 
being endemic in North America and Europe. It is most prevalent 
in autumn and winter (September to February) . It remains endemic 
wherever introduced. Sporadic cases occur. It may occur sporad- 
ically for years and not become epidemic. Epidemics of scarlet 
fever are less frequent than those of measles. It occurs also in epi- 
demics. In epidemics only 38 per cent, of the population are 
affected. There is therefore an immunity of the majority (Jur- 
gensen, on the Faroe Epidemics). As a rule, fully 56 per cent, of 
those exposed before the twentieth year contract the disease. 



SCARLET FEVER. 267 

Incubation. — According to the German authorities, scarlet fever 
has an incubation period of from eight to eleven days. English 
authors (Murchison) fix the period at from three to six days. The 
vast majority of cases develop within a period of from three to five 
days after exposure. If eleven days elapse without the appearance 
of symptoms, we may with reasonable certainty say that the danger 
of infection is passed. Cases of thirty days' incubation are recorded, 
and the author had a case in his practice in which a physician con- 
veyed the disease, the boy being attacked three weeks after his visit. 
In all such prolonged periods of incubation, however, there is a proba- 
bility of a more recent exposure. The contagion is active during the 
period of incubation and during the eruptive and desquamative stages. 
The consensus of opinion is that the contagion diminishes in the 
desquamative stage. In America desquamation is considered a bar 
to the mingling of convalescents with those who are well. In England 
patients are discharged from the hospitals before the desquamation 
is over. We should exercise great caution in allowing convalescents 
to mingle with the healthy, especially if there is a residual otitis or 
adenitis or any purulent focus, for such pus is considered capable of 
conveying the disease. Strange to say, there are no positive data on 
this point. Contagion will be treated more fully under Prophylaxis. 

Immunity. — Although there is no absolute immunity at any age, 
scarlet fever attacks nursing infants lees frequently than older chil- 
dren. We have no positive data as to transmission of the affection 
in utero. Cases are recorded in which the newly born infant has 
been attacked, but some authors are inclined to look on such cases with 
doubt. In certain sets of cases the affection takes on a virulent form, 
in which all the members of a family attacked will have complica- 
tions, septic or otherwise, of a fatal character. All had septic malig- 
nant fever. There may in such cases be an element of mixed infec- 
tion (Henoch). 

Symptomatology.' — Scarlet fever does not present uniform symp- 
toms. A general description of the disease can hardly be given 
without misleading the student. During an epidemic or during the 
prevalence of scarlet fever, there are a number of cases of angina in 
which no exanthema of scarlet fever is seen. This is especially so 
with those whose duties keep them near scarlet fever patients. There 
is no doubt that such anginal cases are capable of conveying the dis- 
ease to others. A case of this kind has come under the author's 
notice. A nurse suffering from an angina went from a scarlet fever 
case to a healthy child. Although the nurse had taken all external 
precautions she conveyed the disease to the child. This raises the 
question of scarlet fever sine exanthema. Let us say that scarlet 
fever poison can cause a specific angina capable o( conveying the dis- 



268 



TEE SPECIFIC INFECTIOUS DISEASES. 



ease to the healthy. Certain forms of exanthema of scarlet fever are 
very evanescent, and in anginal cases may escape observation. 

Period of Incubation. — The period of incubation has no fixed 
symptomatology. In many cases the symptoms begin with the ap- 
pearance of the eruption. The children play about; they have a 
slight angina, but do not complain. This is apt to be the case with 
children who are sufferers from chronic catarrh, enlarged tonsils, or 
adenoids. In other cases the invasion of the disease is a stormy one. 
There may be an initial convulsion preceded by a sharp rise in tem- 
perature. Examination in such cases may show, previous to the 
appearance of the eruption, a marked angina or a membranous deposit 
on the tonsils, but nothing more. Other children suffer from a ton- 
silitis of moderate severity, a marked febrile movement, and, what is 
characteristic, attacks of anorexia and vomiting. A chill, followed 









































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Moderately severe scarlet fever ; female child four years of age. Normal course. 
Observed from the outset. 



by fever and vomiting, ushers in a large number of scarlatinal anginas. 
Occasionally the symptoms of invasions are so mild and evanescent 
as to escape the notice of even watchful parents. These are the cases 
in which the first symptom to attract attention belongs to a later 
period of the disease or to some of the complications. There are thus 
all degrees in the severity of the symptoms of the period of invasion, 
varying with the susceptibility of the subject and the virulence of the 
epidemic. 

General Course of the Disease. — An attack of scarlet fever takes a 
certain general course. After the initial symptoms of vomiting and 
abrupt onset of fever twelve to thirty-six hours elapse, when an erup- 
tion or rash appears on the skin ; this eruption, though characteristic, 
varies greatly in intensity, mode of spreading, and distribution. The 



SCARLET FEVER. 



2M 



fever is now very high; the eruption spreads and becomes more 
intense and general (Fig. 35). At the greatest intensity of the erup- 
tion or florescence the fever is highest. In typical cases of scarlet 
fever the eruption reaches its full development and runs its course 
within two to six days. At the end of this time it fades, and desqua- 
mation begins. The fever subsides gradually, leaving the patient 
convalescent. The period of invasion is not so sharply defined as in 
measles, nor is the stage of eruption so distinct and uniform as in that, 
disease. The length of the period of desquamation in both measles 
and scarlet fever varies. 

The malignant cases may at first appear mild. The children are 
taken with vomiting and a moderately high fever, and the eruption 



Fig. 36. 



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Malignant scarlet fever ; ursemic symptoms from outset. Boy, six years. Sopor 
increasing to coma ; bloody urine. Involuntary passage of urine and faeces. Death in 
three days after onset of symptoms. 



appears. While the eruption is spreading, however, the patients 
become stupid, and within a few hours after the appearance of the 
exanthema pass into a state of coma. The urine is diminished in 
quantity or suppressed, and contains blood, albumin, and casts. The 
temperature remains elevated (Fig. 36). The pulse is rapid and at 
times thready. These patients remain comatose and die within a few 
days (three or four) of the onset of the symptoms. Tn other malig- 
nant cases the affection of the throat and adjacent lymph-nodes is a 
leading factor in the septic phenomena, while the kidneys show vow 
little participation in the general toxaemia. Such patients will show 
necrotic pseudomembranous inflammation in the fauces after the 
eruption is fully developed. The glands of the neck are involved. 
The temperature ranges from L03° to 105° F. (39.4° to t0.5° C), 
with daily remissions. Thepatients have a sallow, septic appearance, 
and are stupid and irritable. The exanthema fades slightly after 



270 THE SPECIFIC INFECTIOUS DISEASES. 

having been in efflorescence. The lymph-nodes in the neck enlarge 
to great size. These patients may die in, the second week from gen- 
eral toxaemia. Between the normal course and these malignant forms 
there are all degrees of severity and mildness in this affection. 

Surgical Scarlet or Infection of Wounds with Scarlet Fever. — 
Maunder and Murchison called attention to the fact that patients 
with wounds are prone to contract scarlet fever more readily than 
others. Hermann has recently reported several cases. It is of in- 
terest that burns are apt to be followed by an outbreak of scarlet fever. 
Leiner has described such cases and I have seen a number and observed 
very active and extensive desquamation follow the fading of the erup- 
tion as well as complicating nephritis. 

The Angina. — The angina of scarlet fever is limited to the pillars 
of the fauces, the uvula, the tonsils, and retropharynx. The angina 
may be simply a slight redness of the fauces and very slight swelling 
of both tonsils. The lymph-nodes at the angle of the jaw may be 
very slightly enlarged. The tonsils may be so greatly enlarged as 
to close the opening of the fauces. This is likely to be the case if 
there has been antecedent hypertrophy of the tonsils. ~No mem- 
branous deposit may be seen, yet there may be a distinct lacunar 
form of tonsillitis. The lymph-nodes at the angle of the jaw may 
be much larger than in the milder anginal cases. The swelling of 
the lymph-nodes may involve the connective tissue about them in a 
phlegmonous mass. This is especially so in the severe septic forms 
of scarlatinal angina of the streptococcus variety. 

Membranous Angina. — Membrane spreading to the pillars of the 
fauces may be present on one or both tonsils. This condition was 
formerly called scarlatinal diphtheria. In the vast number of cases 
of scarlet fever — in fact, in all the uncomplicated cases — this mem- 
brane is not a true diphtheria like the diphtheria of Loffler. It is a 
streptococcus membrane (diphtheroid), caused by the streptococcus 
of pseudomembranous formations. This membrane may involve the 
posterior pharynx and nares, and spread downward into the larynx 
and trachea. True diphtheria of Loffler occurs in those cases of 
scarlet fever which have been exposed to the infection of diphtheria 
at or about the time of the outbreak of the scarlet fever or at some 
period during the course of the disease. The membrane in these cases 
will show, on examination, the Bacillus diphtheria? of Loffler. These 
cases of true diphtheria complicating scarlet fever are exceptional. 

The pseudodiphtheria is usually caused by a streptococcus of the 
scarlatinous variety. In some forms of scarlet fever this pseudo- 
membranous inflammation of the tonsils becomes a primary factor in 
the disease at an early period before the full development of the erup- 
tion. This process involves the lymph-nodes and the whole connective 



SC ABLET FEVEE. ''2.1 1 

tissue of the neck below the jaw in a necrotic streptococcus inflamma- 
tion. In many cases a true streptococcsemia may result from the 
entrance of the streptococci into the circulation. In other cases the 
patient may have passed through a mild eruptive stage and on the 
tenth to the fourteenth day a severe pseudomembranous tonsillitis 
makes its appearance with marked glandular enlargements and high 
fever. Some of these cases are also complicated with a severe 
nephritis. Eetropharyngeal abscess, mediastinal burrowing abscess, 
abscess pointing on the external portion of the neck, or empyema, may 
result from the necrotic tonsillar affection by extension through the 
lymph-nodes. Secondarily, a general systemic infection may result 
in such cases. 

The mucous membrane of the mouth presents nothing character- 
istic in the great majority of cases of scarlet fever. The buccal 
mucous membrane is pale, and of a normal hue at first; the soft 
palate may present a few red, irregularly shaped spots or red streaked 
areas, or these may be absent. Later in the course of the disease a 
stomatitis may appear. This is more likely to occur in the so-called 
septic case. In these the superficial epithelium is removed; the 
mucous membrane has a dry, red, beefy appearance. The lips are 
fissured and bleed easily. 

The tongue in most cases of scarlet fever is furred at the outset, 
and may present a slightly reddened appearance at the borders and 
tip. In some cases there is the so-called characteristic strawberry 
tongue. This appearance is caused by an undue prominence and 
erection of the papillae of the tongue, especially at the tip. The tip 
is red, and with the prominent papillae gives the appearance of a 
strawberry or of the tongue of the lower animals (cat). In many 
cases the tongue later becomes denuded of epithelium and shows the 
erected papillae on the dorsum ; in others it becomes dry and fissured. 
The latter condition is seen in the toxic cases. 

The Exanthema. — The exanthema of scarlet fever, though very 
characteristic in appearance, varies more than in any of the other 
exanthemata in mode of appearance, distribution, spreading, and in 
duration. In the mild cases the eruption is sometimes so evanescent 
as to escape notice. In other cases it appears only on certain parts 
of the surface. It may be very discrete in form and punctate. 
Usually it first appears on the upper part of the chest about the clavi- 
cles, spreads down the chest, and around upon the back. At this 
time it is also seen on the neck, beneath the jaw. behind the cars, and 
on the temples. 

It consists of a minute, delicately punctate rose-colored rash. 
The punctate appearance is the distinguishing feature of the erup- 
tion. At the outset this punctate character is best observed on the 



272 TEE SPECIFIC INFECTIOUS DISEASES. 

chest, abdomen, and the nates. If the eruption has in places become 
confluent, the skin shows a uniform redness. In such cases the punc- 
tate character of the rash can best be discovered by studying the skin 
from a distance in bright daylight. It will then be made out dis- 
tinctly in those places in which the rash is most recent. A favorite 
method is to undress the patient and study the lower abdomen, the 
thighs, and nates. In the early cases the punctate character of the 
rash is apparent on the neck and behind the ears. 

The appearance of the face at the outset of the disease is charac- 
teristic. There is a pallor about the mouth and alse nasi, while the 
cheeks are flushed with a flame-like erythema. The eyes may be 
injected. The cheeks do not show the characteristic punctate rash, 
although flushed either from the fever or intense dermatitis, which 
involves the whole surface. The eruption spreads from above down- 
ward, involving the arms and forearms, hands, and lower extremities. 
It retains the punctate character wherever it spreads, but loses this 
characteristic after it has been out for a short time and become con- 
fluent. When confluent the rash causes the skin to appear uniformly 
red and swollen. In some places, especially the extensor surface 
of the hands and forearms, the eruption is blotchy and erythema- 
tous. The skin is roughened in patches by the erection of the papillae. 
In other cases, and especially in those occurring in summer, the skin 
is studded with myriads of minute vesicles, or, again, the skin may 
present minute pustules. There is pruritus in the cases in which the 
dermatitis is severe. The rash of scarlet fever attains its full devel- 
opment at the end of two or three days. It is then said to be in 
efflorescence. It remains out a variable length of time, in some cases 
six days. In other cases the eruption may develop fully in two days 
and then fade. Cases in which the rash is visible for only twenty- 
four hours are not uncommon. 

The appearance of a fading scarlet fever rash is very character- 
istic if it has involved the whole surface. The skin is dotted here 
and there by raised papilla?, and appears as if irregularly and lightly 
daubed with rouge. Even a fading rash may be easily diagnosed by 
an experienced observer. In mild cases the rash may disappear 
within twelve hours, leaving no vestige of its presence. In other 
cases the rash appears only on the lower part of the abdomen and 
upper part of the thighs. 

The eruption on the lower part of the extensor surface of the 
forearms, and also on that of the legs, is apt to assume a blotchy, 
roseola-like appearance. Such cases have been mistaken for measles. 

Abscesses or furuncles, multiple or single, may involve the skin. 
In rare cases gangrenous processes have been recorded. A secondary 
infection may be assumed in all of these cases. 



SCA BLET FE VER. 2 ( 6 

The Fever. — In the first few hours there is a rapid rise of the 
temperature to 104° or 105.8° F.(40° or 41° 0.). It remains high with 
morning remissions until the eruption on the surface reaches its full 
development. With the fading of the eruption the temperature falls, 
and within six days, if the case is uncomplicated and typical, becomes 
subnormal. The patient may show a subnormal temperature for a 
few days, after which it may rise to the normal. In some cases the 
temperature may rise very rapidly, reaching its highest point within 
a few hours. It may then fall to the normal rapidly, though the 
eruption be still present. Wunderlich and Henoch record cases of 
profuse exanthema with a mild febrile course or practically afebrile 
curve, 101° F. (38.4° C), falling rapidly to 100.4° F. '(38° C.) 
within twenty-four hours. 

In those cases in which there are complications either in the 
throat, ear, joints (rheumatism), or serous cavities, the temperature- 
curve will be influenced accordingly and will continue for days at a 
low range, 102° to 103°, with daily remissions. In other cases, 
evening remissions may occur instead of morning ones. After the 
fading of the eruption the fever may continue for days, 3 00.4° to 
102.2° F. (38° to 39° C), in the absence of any complication. 
After days or weeks of absence of temperature there may occur a 
distinct rise and a species of relapse similar to that seen in typhoid 
fever. This is probably due to a form of secondary streptococcus 
infection. During the height of the eruption the temperature may 
reach 107° F. (41.6° C), although in mild cases it may not be over 
103° F. (39.4° C). In cases of septic infection, especially of the 
lymph-nodes, or in streptococcus diphtheria, with infection of the 
lymph-nodes, the temperature-curve will be of a remittent character, 
falling and rising once or twice in twenty-four hours, and may retain 
this character throughout the affection. Uraemia or any affection of 
the pleura, lungs, or heart will be ushered in by a rise of temperature 
even if it has returned to the normal. If a complication occurs early 
in the disease, the temperature will fail to drop to normal with the 
fading of the eruption (Fig. 34). In cases of otitis persisting through 
the stage of desquamation there will sometimes be an evening rise, 
although the ears are discharging freely. In such cases the bone may 
be involved (mastoid disease). In severe, malignant forms in which 
symptoms of profound sepsis, such as coma or stupor, are present 
from the outset, the temperature remains persistently high ^10;V6" 
F., 40.8° C), remitting a degree toward morning. The temperature 
remains high until the fatal issue (see Fig. 36). 

Desquamation. — The period of desquamation begins as soon as 
the exanthema commences to fade. Generally speaking, since the 
exanthema first appears on the upper part o( the chest and neck Ave 

18 



274 



THE SPECIFIC INFECTIOUS DISEASES. 



should expect desquamation to begin there. It may be in fine, branny 
scales, such as are seen in measles; or else, as is most common, the 
skin peels in larger particles. The hands and feet show the largest 
scales, and complete casts of the hands and feet are sometimes shed. 
I have seen the nails shed completely twelve weeks after the attack. 
The desquamation may be scarcely perceptible. In some cases only 
certain parts of the extremities, such as the toes or inner portion of 
the thighs, show desquamation. It is, however, always present. 
Desquamation in itself is not a pathognomonic symptom of scarlet 
fever. It occurs in forms of dermatitis which bear no relationship 
to the disease. It is still a subject of debate whether cases of angina 
without an exanthema may desquamate. Henoch is inclined to think 

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Scarlet fever, moderate severity, in a boy six years of age. Shows the delay in the 
drop of the temperature due to complicating otitis of the right ear at the outset of the 
period of desquamation. 



this possible. We should remember that an evanescent, slightly 
marked exanthema may escape the notice of even the most careful 
observer. 

The duration of desquamation is variable. There are cases in 
which a secondary desquamation occurs after the primary one has run 
its course. The severity of desquamation has no relation to the 
intensity of the exanthema. Some very marked cases of scarlatina 
desquamate less than those in which the eruption has been faintly 
marked. The average duration of desquamation is six weeks 
(Kellogg) : 

The Nose. — The close relationship of the nasal passages to the 
pharynx facilitates the invasion of bacteria from the throat. The 
nasal passages become affected simultaneously with the severe angina. 
There is a severe catarrhal or pseudomembranous inflammation of 
the mucous membrane. In the so-called septic cases there may be 
an ichorous discharge from the nostrils. There will be in such cases 
erosions, and sometimes fetor, with the discharge of necrotic tissue 
through the nasal passages. Necrosis of the cartilaginous and bony 



SC ABLET FEVER. 



275 



structures may result. In other forms there is a pseudomembranous 
deposit around the opening of the nostrils extending up into the nasal 
passages. Casts of the nasal passages may he expelled. The mem- 
brane may leave a bleeding surface. 

Ear. — Duel found the ears affected in 20 per cent, of the cases 
of scarlet fever. Generally both ears are diseased. Deafness is 
frequently a result of otitis. Ten per cent, of those who suffer from 
deaf-mutism can trace their affliction to scarlet fever. Usually the 
ears become affected in the third week, although they may be involved 
at the outset of desquamation. The affection of the ears is ushered 
in by a rise of temperature and manifestations of pain (Fig. 38). 
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Female child, two and a half years of age. A mild form of scarlet fever complicated in 
the second week by an otitis. 



may be convulsions or even cerebral symptoms. The onset of ear 
trouble may be insidious, and not suspected until the purulent dis- 
charge makes its appearance. If there are premonitory symptoms, 
they may precede the perforation by one to three days. Ear compli- 
cations in scarlet fever are alwavs of serious moment. Meningitis, 
sinus thrombosis, and abscess of the brain are among the more serious 
results, and may result long after the fever has run its course. The 
onset of otitis usually occurs during the period of desquamation. 
The patient may be up and about. There is still some redness of 
the throat, with swelling of the lymph-nodes. There is a sudden rise 
of temperature to 103° or 104° F. (39.4° or 40° C). The child 
begins to vomit food and has headache. At night the child starts 
from sleep and cries as if in pain. Children do not always locate 
the pain in the ear. The reason is that the pain occurs before the 
child is quite awake. The sleep is restless. The muscles of the face 
and hands twitch in sleep. These symptoms may at times abate. 
The temperature may fall to the normal and thou vise sharply. Anv 
of these symptoms should direcl attention to the ear. 



276 TEE SPECIFIC INFECTIOUS DISEASES. 

The mastoid may become the seat of inflammation in the fifth or 
sixth week. The ears may have been discharging very freely. The 
child is not, however, free from fever. At times during the day the 
patient complains of frontal headache, is drowsy, and the temperature 
shows a rise to 102° or 103° F. (38.5° or 39.9° C). There is ten- 
derness behind the ear or in front of the auditory meatus. There 
may be a slight blush above and behind the pinna. In these cases 
the mastoid may be the seat 'of suppuration. There are forms of 
otitis which occur on the eighth day of the disease. The temperature 
does not fall to the normal. The patient has begun to desquamate, 
but the temperature remains elevated a degree or more and takes 
fully three or four days longer to fall to 99° F. (37.2° C.) in the 
rectum than in an uncomplicated case. At the eleventh day of the 
disease pain is complained of. The drumhead is found to be bulging. 
An insidious serous otitis media is in progress. 

The Eye. — Conjunctivitis may appear in some cases of scarlet 
fever as a result of a mixed infection. The lachrymal duct is the 
canal through which such infection travels. Conjunctivitis in cases 
of gangrenous pharyngitis and rhinitis may lead to panophthalmitis 
and destruction of the eye. 

Lymph-nodes. — The lymph-nodes in various parts of the body 
enlarge in scarlet fever. Those situated at the back of the neck 
behind the posterior border of the sternomastoid muscle may enlarge 
some days before the appearance of the exanthema. At the time of the 
appearance of the eruption we may find that the lymph-nodes in the 
axilla, inguinal region, and those at the angle of the jaw, are enlarged. 
In other cases the lymph-nodes, except those at the angle of the jaw, 
may not be perceptibly enlarged. In some cases the lymph-nodes at 
the angle of the jaw may enlarge at the end of the second week, with 
a distinct rise of temperature to 104° F. (40° C.) or more, as a 
result of reinfection through the tonsils and pharynx. The con- 
nective tissue of the neck beneath the body of the jaw is involved in 
the inflammation of the nodes. In such cases the swelling has an 
appearance similar to that seen in angina Ludovici. In severe mixed 
infection the tissues of the neck may become gangrenous. As a result 
of such severe gangrenous inflammation, phlebitis erosion into the 
veins and arteries with fatal hemorrhage may result. Retropharyn- 
geal abscess or retropharyngeal adenitis is a sequence of infection of 
the lymph-nodes. The retropharyngeal abscess in such cases is not 
as benign as that occurring independently of scarlet fever. In the 
latter the abscess is apt to involve a chain of retropharyngeal nodes. 
Multiple burrowing abscesses result. The nodes of the mediastinum 
may be affected, causing empyema or pericarditis. The mediastinal 
abscess may cause death by pressure on the trachea, or by eroding the 
trachea, burst into it and cause death through suffocation. 



SCARLET FEVER. 



211 



. The Mouth. — Stomatitis always occurs in severe scarlet fever. It 
may be simply a mild catarrhal process. If there is a pseudomem- 
branous formation on the tonsils, this pseudomembrane may spread 
to the mucous membrane of the soft palate, and the buccal mucous 
membrane may also become affected. The tongue is dry and fissured ; 
the lips are dry, fissured, and bleed easily. There may be a discharge 
of necrotic tissue from the mouth. The soft palate, tonsils, and 
pharynx may be fused into a necrotic mass, emitting an offensive odor. 
Joints. — The joints become inflamed in from 2 to 6 per cent, of 
the cases of scarlet fever. This affection of the joints has been called 



Fig. 39. 




Boy five years of age, observed from the outset of the disease. Scarlet fever with joint- 
complications. No cardiac involvement. Recovery. 

scarlatinal rheumatism. The joint-affection may, in exceptional 
cases, precede the exanthema. It appears, as a rule, in the second 
or third week of the disease (Fig. 39), and is therefore one of the 
manifestations seen during desquamation. There may be pain in 
several articulations. In other cases swelling may occur, with effu- 
sion of serum into the joints. These cases retrograde. There may 
be a complicating endocarditis. In other cases there is suppuration 
of the joint. An arthritis with streptococci in the joint-effusion 
results. The streptococci invade the joint through the epiphyses of 
the bone, and produce a streptococcus osteomyelitis with suppuration 
of the adjacent joints (Lannelongue, Achard, Koplik, Van Arsdale). 

As a rule, suppuration occurs in only one joint. Cases in which 
several joints are affected are generally septic, streptococci having 
gained access to the general circulation through a necrotic focus in 
the throat or pharynx. Such cases are fatal. There are metastases 
in the lungs, kidneys, pleura, and pericardium, with hemorrhages in 
the skin and enlargement of the spleen. Periarticular abscesses 
rarely occur (Henoch). The prognosis is serious in all suppura- 
tive cases. 

The Kidneys. — In scarlet fever, as in most infectious diseases, 
there may be a mild form of nephritis in the earlier stages. There 
are a small amount of albumin and a few hyaline casts in the urine. 
This nephritis is of little significance, and has nothing in common 



2/8 TEE SPECIFIC INFECTIOUS DISEASES. 

with the severer form which occurs later in the disease. The severe 
form of nephritis begins as a rule in the third week. It has been 
known to appear in the sixth week. The frequency of this compli- 
cation varies in different epidemics. In some, only a small number 
of cases are affected (5 per cent.). In other epidemics fully 70 per 
cent, of the cases are thus complicated. Its occurrence cannot always 
be predicted from the severity of the disease. The mildest cases may 
develop severe nephritis. The diphtheritic forms of angina are more 
likely to be complicated with or followed by nephritis. On the other 
hand, the severest forms of scarlet fever may run their course without 
marked nephritis. Sorensen has shown that at autopsy the most 
marked changes may be found in the kidneys, although no clinical 
signs of the affection have been manifested during life. In 50 per 
cent, of the autopsies upon scarlet fever patients Friedlander found 
changes in the kidneys. It was formerly thought that exposure played 
an etiological role in this affection, but this view has been abandoned. 

Nephritis may develop in cases which have been very carefully 
guarded from exposure from the outset. Although the symptoms will 
be detailed elsewhere, it may be here stated that the first symptom is 
a slight oedema about the eyes and face which spreads to the rest of 
the body, involving the trunk and extremities, the hands and dorsum 
of the feet, and the scrotum. In some cases the oedema is not marked, 
in others the anasarca is extreme. The serous cavities may become 
the seat of effusion, and there may be hydrothorax, hydropericardium, 
or ascites. 

The urine also shows changes very early. The quantity dimin- 
ishes very rapidly, or it may be completely suppressed. The urine 
shows the presence of albumin, rarely more than 0.5 per cent. It 
may be highly colored or smoky, or may be distinctly red in color, 
owing to the large amount of blood and blood-pigment contained. 
The urine in cases of partial or complete suppression generally con- 
tains a large amount of albumin, blood, hyaline, epithelium, and 
blood-casts, renal epithelium, and leucocytes. The specific gravity 
may at first be high, 1.030 ; later, when diuresis is inaugurated, it 
may fall to 1.006. All cases do not run a course with anasarca. 
There are cases without this symptom. The invasion of the affection 
is sometimes marked either by a rise of temperature or convulsions. 

The prognosis is good in spite of the very alarming symptoms, 
such as convulsions and coma, which are seen in some cases. This 
nephritis usually runs its course in from four to six weeks, leaving 
the kidneys intact. Sometimes the nephritis apparently subsides, 
but albuminuria of a very mild or intermittent form persists for 
months. In fact, many of the so-called cases of paroxysmal albumi- 
nuria are probably due to unobserved scarlatinal nephritis. Finally, 



SCARLET FEVER. 279 

there are cases in which the anasarca recurs at long intervals as a 
result of chronic diffuse nephritis. 

Urcemia. — Uraemia commonly sets in with a diminution in the 
whole quantity of urine passed daily. It may supervene without 
any distinct change in the quantity or quality of the urinary excre- 
tion (Henoch). In these cases the changes in the urine follow the 
appearance of the ursemic symptoms. Uraemia may also appear not- 
withstanding the passage of an increased amount of urine. The 
latter mode of onset in ursemia is very uncommon. The early 
symptoms are vomiting, headache, and slight twitching of the facial 
muscles. These may subside with the abatement of the nephritis. 
We may have, however, eclampsia as the first symptom, with tonic 
or clonic convulsions, unconsciousness, and coma with temporary 
absence of the reflexes. The respirations are increased, and in most 
cases the temperature rises. The pulse is small and the skin dry. 
The convulsions may subside, but the coma may continue. The 
eclamptic seizures may be repeated. The ursemia may subside, and 
after a very protracted interval reappear with a repetition of the 
above phenomena. Mania, melancholia, and aphasia may ensue. 

Amaurosis without changes in the retina is a more common con- 
dition. The retinitis of Bright's disease is absent in scarlet fever. 
Litten found a swollen condition of the papilla. Amaurosis may 
persist in the intervals between the convulsions. 

The heart action immediately preceding the convulsions is slow. 
The pulse may be as low as 40 per minute. During the convulsions 
the heart action is increased. The respirations may be 60 and the 
pulse 200 (Jiirgensen). 

The temperature may be 100.4°-103° F. (38°-39.5° C), rarely 
107.6° F. (42° C), with an initial chill (Jiirgensen). 

Ursemia may set in at any time while the kidney is affected. 

The Heart. — Myocarditis of an acute infectious character is likely 
to supervene in septic cases of scarlet fever. The changes in the 
myocardium may also be secondary to changes in the pericardium 
and endocardium. 

Endocarditis of the cardiac walls is more frequent than that of 
the valves. For this reason murmurs should be carefully observed. 
No conclusions as to their valvular origin can be reached until long 
after convalescence. Especially is this true of murmurs which are 
heard over the base of the heart and pulmonic orifice. Endocarditis 
is uncommon, but is more frequent in this disease than in diphtheria 
or typhoid fever. 

Pericarditis is rare. Muscle murmur is often mistaken for it. 
If present, pericarditis is usually of the dry fibrinous or serofibrinous 
variety. It is rarely purulent, except in eases of marked purulent 
involvement of other organs and cavities, notably the pleura. 



280 THE SPECIFIC INFECTIOUS DISEASES. 

Dilatation of an acute character may supervene early in severe 
cases. In such cases we may have tachycardia or bradycardia. 
There may be cyanosis. Sudden death is very rare in scarlet fever. 

Friedlander has shown that in scarlet fever with marked nephritis 
and uraemia, the consequent increased arterial tension results in dila- 
tation of the left ventricle, with slight hypertrophy. The weight 
of the heart is increased 40 per cent. The pulse may be slow and 
irregular. As the nephritis subsides the tension diminishes and the 
frequency of the pulse increases. Hypertrophy being the result of 
long-continued increased tension, can be demonstrated only in extreme 
cases. Dilatation is rarely so great as to cause death. 

Lungs. — The lungs may be affected by pneumonia, which is gen- 
erally of the bronchopneumonic type. Lobar pneumonia as a com- 
plication of scarlet fever is rare. Gangrene of the lung may occur in 
the severe septic cases. 

Pleura. — Pleuritis as a complication of scarlet fever usually 
appears in the middle of the second week. It is commonly of the 
serous variety, but the author has had many cases in which there 
was an empyema usually of the streptococcic variety. Fiirbringer 
states that in 5 per cent, of the cases of pleurisy there is nephritis. 

The Blood. — There is a diminution of the haemoglobin, which is 
marked in cases in which nephritis is present. During convalescence 
the haemoglobin increases. Slight leukocytosis is also present in the 
course of the disease. Marked leucocytosis occurs with suppurative 
complications such as otitis, adenitis or empyema. There may be 
purpura and surface hemorrhages. 

Stomach and Intestine.- — Vomiting has been mentioned as an 
early symptom in scarlet fever. It is sometimes repeated in the 
course of the disease if a cough due to any laryngeal or pulmonary 
complication exists. Diarrhoea is sometimes a serious complication. 
There may be a simple diarrhoea, in which an excessive number of 
movements may threaten the life of the patient early in the disease ; 
or, on the other hand, the diarrhoea may subside without serious 
results. The diarrhoea may take on a dysenteric or typhoidal type, 
with severe hemorrhages from the gut. There are some forms of 
diphtheria of the pharynx, stomach, and large intestine in the septic 
types of scarlet fever which have been described by Litten. 

Sequelae. — As sequelae to scarlet fever may be mentioned : 

Anaemia. — This may persist for some time. 

Glandular Swellings. — The lymph-nodes at the angle of the jaw 
are apt to remain enlarged long after convalescence. The tonsils 
may remain large. 

Tuberculosis. — Tuberculosis may follow scarlet fever. It cannot 
be said that there is any distinct connection between the two diseases. 



SCARLET FEVER. 28 1 

Scarlet fever may leave the patient more susceptible to infection 
either of acute miliary or chronic tuberculosis. 

Nervous Diseases. — Chorea has been noted by Gerhardt to follow 
scarlet fever, as have also rheumatic joint-affections with endocarditis. 

Facial paralysis may occur as the result of prolonged otitis. 

Psychoses, such as melancholia and mania, have been noted, 
similar to those following typhoid fever or pneumonia. 

Otitis. — Otitis may remain with a permanent discharge and con- 
sequent deafness or mutism. 

Relapses or Second Attacks. — There are no relapses in the true 
sense in scarlet fever, but instances occur in which after the primary 
eruption has faded a new and general scarlatinous rash appears. In 
others, the disease runs an exceedingly mild course, the rash is evanes- 
cent and lasts only a short time, and the temperature falls quickly 
to the normal. After ten to fourteen days, a rise of temperature 
occurs, the lymph-nodes at the angle of the jaw enlarge and the tonsils 
also enlarge and become covered with a pseudomembrane. The 
temperature is quite high. Albuminuria and nephritis of a severe 
type may appear at this time. Second and third attacks of scarlet 
fever are found recorded in the literature. I have not seen any in 
which I have personally diagnosed two attacks. The suspicion 
always is present that in these cases rotheln may have been diagnosed 
as scarlet fever. 

Diagnosis. — The diagnosis of scarlet fever in most cases presents 
few difficulties; but there is no disease in which the symptoms are 
more indefinite at times. This is particularly so with patients who 
present an evanescent or partial exanthema and only slight febrile 
disturbance. In some cases the diagnosis must always remain in 
doubt. Under these conditions it is better to err on the safe side, 
and to take all precautions of isolation. The exanthema if partial 
or not very well marked is likely to be overlooked. The angina. 
which is the most constant symptom, may be mild. The temperature 
presents nothing typical as in typhoid fever. 

It is good practice in the presence of a localized exanthema of a 
punctate character on the thighs or lower abdomen or the upper part 
of the chest, with angina and a slight febrile movement, to consider 
the case as one of scarlet fever. In all cases of sore throat it is wise 
not to omit an inspection of the general surface. Although some 
authors have described the angina of scarlet fever as typical in color, 
the author has never found this sign of value. In some eases of 
scarlatinal angina the throat is intensely red; in other eases it is of a 
pale-pink hue; in still others the throat is only slightly inflamed. 

Enanthema. — The enanthema is not of any service in making a 
diagnosis. The eruption on the soft and on the hard palate is not 
characteristic. 



282 THE SPECIFIC INFECTIOUS DISEASES. 

Albumin. — Albumin in the urine is thought by some to be diag- 
nostic of scarlet fever. There may be marked and unmistakable 
symptoms of scarlet fever without albuminuria. A simple lacunar 
amygdalitis may be accompanied by albuminuria. 

Differential Diagnosis. — We must differentiate the eruption of 
scarlet fever from that of measles and rotheln, from drug eruptions, 
and those due to irritants. 

Measles. — In some forms of scarlet fever the eruption on the 
forearms has a blotchy appearance. Near the wrist-joint the author 
has seen it closely resemble the eruption of measles. In these cases 
the punctate character of the eruption elsewhere on the surface, and 
the presence of angina, will assist us, in the absence of any enan- 
thema on the buccal mucous membrane ("Koplik's spots") (Plate 
XIV.), in coming to a conclusion. In measles the diffuse localization 
of the exanthema on the face, the conjunctivitis and bronchitis, will 
aid us. In scarlet fever parts of the face, such as the alse nasi and the 
region of the mouth, are free from eruption, while in measles these 
localities are affected by the exanthema. 

Rotheln. — Scarlet fever is most frequently mistaken for rotheln, 
and vice versa. 

In rotheln, when the eruption is punctate, it is invariably dis- 
crete. There is never the severe dermatitis with swelling of the 
skin found in scarlet fever. In rotheln the lymph-nodes are more 
constantly and generally swollen behind the sterno-mastoid, in the 
axillae and groin. The throat is but slightly reddened. Rotheln 
presents a normal temperature or at most a temperature at the outset 
of the eruption of 101°-102° F. (38.3°-38.8° C.) or even 103° F. 
(39.4° C), which rapidly subsides to the normal, although the exan- 
thema may be spreading. 

Drug Eruptions. — Following the administration of quinine chil- 
dren develop an eruption which closely resembles that of scarlet fever. 
In the presence of an angina and fever it may be difficult to exclude 
scarlet fever. Antitoxin of diphtheria, antipyrin, and belladonna 
also cause a rash closely resembling that of scarlet fever. It is well 
in such cases to discontinue the drug, and after a few days, the erup- 
tion having disappeared, to administer it again. If the patient be 
susceptible, there will be a repetition of skin symptoms. Kerosene 
rubbed on the surface will cause a punctate eruption the exact coun- 
terpart of a scarlet fever eruption. Among the poor, with whom 
petroleum is popular as a general remedy, this should be borne in 
mind. If that has been the case, the skin will have a distinct odor 
of kerosene. 

Prognosis. — The prognosis in scarlet fever varies largely with the 
character of the epidemic and the prevalent type of the disease. In 



SC ABLET FEVEB. 283 

some epidemics in New York City the mortality has been exceed- 
ingly low — 2 to 4 per cent. (J. L. Smith), while in others it has 
been notably high. In England the mortality varies from 13 to 40 
per cent. 

Personal idiosyncrasy will affect the prognosis. Some children 
develop malignant septic types of the disease although the prevailing 
epidemic is mild. 

Cases complicated with severe angina septic in character do badly 
from the outset. 

Nephritis is a complication greatly to be feared. It may result 
in uraemia and death, or the acute may be followed by a chronic 
nephritis which may ultimately prove fatal. 

Otitis may cause serious and even fatal complications, such as 
brain abscess or sinus thrombosis. 

Affections of the endocardium or pleura may prove fatal. 

The prognosis of the so-called scarlatinal rheumatism is good. 
The joints, even if synovitis develops, retrograde as a rule to the 
normal in from two to three weeks. This may result even if high 
fever persists for some time during the joint-affection. In the pres- 
ence of joint-complications it is necessary to be on the lookout for 
endocarditis or pericarditis. The occurrence of the latter takes place, 
as a rule, in cases in which there are other signs of septic infection, 
such as pleuritis and even peritonitis. These are cases of mixed 
infection. If synovitis is complicated with such a serious inflamma- 
tion as pericarditis, the latter is very likely to be purulent and in that 
case the prognosis is grave. 

The patient cannot be said to be out of danger until the fourth 
week of the disease has passed without serious complications. A very 
high temperature at the outset is an element of danger, although not 
necessarily so. Septic cases with high temperature and pulse above 
150 in the first week of the disease are always to be regarded with 
apprehension. 

Lotz shows that the mortality is greatest under the age of one 
year and between the first and second years. The lowest mortality 
according to statistics occurs between the tenth and the fifteenth years. 

Morbid Anatomy. — Skin. — The investigations of Preobrachenskv 
and Pearce show that during the interval from the third day to the 
fourth week certain changes occur in the skin. These consist chiefly 
in an erythematous inflammation of the papillary layer, with hyper- 
emia, hemorrhages, and a diapedesis of erythrocytes and leucocytes. 
There is an oedematous infiltration of the connective tissue of the skin. 
The cells of the rete Malpighii show vacuolization. There is also an 
infiltration of the sudoriparous and sebaceous glands with small round 
cells. The epithelium of these glands desquamates and necroses. 



284 TEE SPECIFIC INFECTIOUS DISEASES. 

At the time of the eruption streptococci are found in the skin, espe- 
cially in the vesicles of the sudamina. 

The changes in the kidneys will be considered in the chapter on 
Diseases of the Kidney. 

Bacteriology.- — -The parasitic nature of scarlet fever is still a 
matter for study. Streptococci play a leading role in the disease. 
Micro-organisms have been described in the blood (Hallier, Klebs, 
Tschamer). Others have seen plasmodium-like protozoa in the blood 
(Pfeiffer, Doehle). Pearce concludes that the bacteria which pro- 
duce secondary infections are the Streptococci, Staphylococci and 
Pneumococci in order of frequency as named. 

Streptococci have been found in the throat membranes (Loftier), 
in the joints (Litten, Heubner, Koplik, Yan Arsdale), and in various 
viscera (Frankel, Freudenberg). Streptococci have also been found 
in purulent foci of the joints and pleura (Raskin), and in the kid- 
neys, in cases which have succumbed to fatal nephritis (Babes). In 
septic forms of scarlet fever these streptococci exist in the circulating 
blood (Babes, Lenhartz, Peer). Streptococci have also been found 
in the cerebrospinal fluid and bone-marrow (Baginsky). Bacteriol- 
ogists, however, are not willing to assign to these streptococci anything 
but a secondary role, because they present no features which distin- 
guish them from ordinary Streptococcus pyogenes. Kurth found that 
some of the streptococci, the so-called conglomerate-forming strepto- 
cocci, were of a virulent type. The more important complications, 
such as pneumonia, otitis, adenitis, pleuritis, disease of the antrum 
of Highmore, abscess of the lung and kidney, endocarditis and inflam- 
mation of the sphenoidal sinuses are caused by Streptococci (Pearce). 

Bretonneau, Henoch, and Heubner have always distinguished the 
diphtheria of scarlet fever from true diphtheria. Sorensen describes 
the membranous formations of scarlet fever as milky, yellow, smeary 
deposits which cannot be peeled from the parts. The membrane 
seems to penetrate into the mucous surfaces. Ulcers form, and the 
tonsils, soft palate, uvula, and nasopharynx become a necrotic, slough- 
ing mass. Scarlatinal diphtheria is pre-eminently a septic inflam- 
matory process with high fever, swelling of the lymph-nodes, and 
suppurations in different parts of the body. If the larynx and 
trachea are affected, the bronchi rarely become involved. The con- 
trary is true of Loffler diphtheria. In the latter the membrane can 
be peeled from the surface of the mucous membrane. The membrane 
is rich in fibrin, and spreads more on the surface and not in the 
depths. True diphtheria is followed by paralyses. 

The lesions of the gastro-intestinal tract are degeneration with 
proliferation of epithelium and invasion of leucocytes. In the heart 
there is myocarditis with fatty degeneration, in the liver focal necrosis 



SC ABLET FEVER. 285 

and leucocytic invasion. In the spleen there is endothelial prolifera- 
tion, abundant formation of plasma-cells and leucocytic invasion. 
The kidneys most frequently show acute interstitial nephritis. The 
so-called plasma-cells of Councilman are found in the lymph-nodes, 
kidneys, spleen and tissues (Pearce). 

Prophylaxis. — The diagnosis of scarlet fever once made, the pa- 
tient should be isolated from the rest of the family. If several chil- 
dren are affected in the same family, these children should be sepa- 
rated and not placed in one room. Otherwise reinfections will occur. 
The clothes worn just prior to the illness should be sterilized in steam 
and then aired in the sun. Sufferers with angina who have been 
about the patient should not be allowed to come in contact with the 
healthy. All the children of the family should be kept from school. 
During the illness the bedclothes and linen of the patient should be 
put into. a 1 : 5000 solution of mercuric chloride, prior to being boiled 
and dried and aired in the sun. The sick-room must be kept well 
ventilated. There is no advantage in keeping the temperature of the 
sick-chamber too low. The author has found a temperature of 68° 
F. (20° C.) comfortable for the patient and those about him. Sun- 
shine and fresh air are of more value than a room uncomfortably cool. 
If possible, it is well to spray with some simple cleansing solution 
morning and evening the throats of any children of the family who 
are not affected. 

The physician should take off his coat and vest and put on a 
linen robe of some kind before entering the sick-room. On his 
departure he should leave this robe outside the sick-room, or, better 
still, outside the window of an adjacent room. If the physician 
wears a beard, he should wash his face in a 1 : 2000 solution of 
mercuric chloride after leaving the patient. The hands should also 
be scrupulously disinfected. When he returns home he should make 
a complete change of clothing before visiting other patients. Carpets 
and superfluous furniture should be removed from the sick-room. 
The hanging of sheets wet with disinfectants in the door of the sick- 
room is not essential. 

Those about the sick should have no intercourse with the healthy, 
nor should they go through the house. Meals should be carried by 
others to some neutral spot. 

After convalescence the question of the disinfection of the sick- 
room and its occupation by others arises. It must be confessed that 
at present we are in possession of no absolutely sure method of dis- 
infecting a room after its occupancy by a scarlet fever patient. We 
may adopt one of two methods. The cracks and spaces in the win- 
dows and doors are closed with strips of paper glued over them. The 
disinfectants, preferably a large quantity oi' binoxide of manganese, 



286 TEE SPECIFIC INFECTIOUS DISEASES. 

table salt, and sulphur, are placed in the centre of the room. The 
sulphur is then ignited and the doors sealed. Formalin is also 
effective. After twenty-four hours the room is opened and aired, 
and the floors and walls are scrubbed with 1 : 2000 corrosive subli- 
mate. In hospitals the scrubbing is sufficient. The floor and walls 
about the bed occupied by the patient are scrubbed, and also the bed. 
The mattresses are steamed in a sterilizer constructed for the purpose. 
In families it is best to destroy or burn all bedding of hair. Rugs 
may be aired and disinfected by steam at the establishments equipped 
for the purpose. 

How soon may a scarlet fever patient have intercourse with the 
healthy? We have no exact data on this important point. Some 
authors advise that after the termination of desquamation the patient 
be given a bath of 1 : 10,000 corrosive sublimate, and then allowed to 
mingle with the healthy. Others (Baginsky) advise prolonged isola- 
tion. It is not always practicable, nor indeed desirable, to isolate a 
patient for too long a period. Family considerations demand a return 
to the family circle as soon as possible. In these cases the course first 
mentioned is the most practicable. In cases which have exhibited a 
malignant septic form of the disease the author would advise pro- 
longed isolation after convalescence, for the safety of the other chil- 
dren. The urine of a scarlatinal case if there are even mild signs of 
nephritis, such as albumin and casts, is believed to be infectious. A 
recent otitic discharge is thought to be capable of conveying the scar- 
latinal poison. 

Treatment. — The treatment of scarlet fever is largely symptomatic. 
In an ordinary mild case there is little to do but to regulate the diet, 
and keep the nose and throat freed from excess of secretion. 

The diet should consist mostly of milk, matzoon, junket, malted 
milk, cream and water; later on farinaceous gruels, cream soups, 
bread, toast and milk. Water should be freely given at frequent 
intervals. 

The skin needs a little care. During desquamation it is anointed 
once a day with a 1 per cent, salicylic acid or boric acid ointment, to 
be stopped after the first week. If there is pruritus the following 
lotion, recommended by Kellogg, is useful : 

Calamine 5j 4.00 

Zinc oxide 3 ss 2.00 

Aqua rosae 5 j 30.00 

Glycerin TTL xv 1.00 

The urine should be examined daily,- for even in the mildest cases 
severe nephritis is apt to intervene. Vigilance should not be relaxed 
until after the fourth week. 



SCARLET FEVER. 287 

The fever in simple cases needs only the mildest measures. We 
should remember that the tendency of the fever is to mount until the 
eruption is fully developed. It then naturally remits. Thus a tem- 
perature of 105° F. (40.5° C.) in an ordinary uncomplicated case 
may not last more than a few hours. In ordinary cases sponging 
with lukewarm water is efficacious. The aim is not so much to 
reduce the temperature as to support the nervous system and the 
heart. In private practice it is well not to resort at once to full baths 
simply because the temperature is above 104° F. (40° C). The 
reverse is true with temperatures which are persistently high for days. 
In such cases the author resorts to full baths. The patient is placed 
in a bath at 100° F. (37.7° C), and the water cooled to 85° F. 
(29.4° C). With children it is well not to resort to lower tempera- 
tures. This is especially true in the asthenic forms of sepsis. The 
patients fail to react after the bath, and seem weakened by the exces- 
sive cold. The patients remain in the bath about five minutes, and 
are then taken out. In cases in which the temperature mounts above 
105° F. (40.5° C.) we may employ the pack at a temperature of 70° 
F. (21.1° C), with much benefit if the reaction is good. The trunk 
pack may be repeated every one or two hours. The baths above 
described may be given every four hours. While the patients are in 
the bath reaction may be promoted by mild friction. Patients with 
scarlet fever, especially young children, do not bear baths below 75° 
F. (23.8° C.) well. The old theory that kidney complications are 
caused by cold baths is not proved. On the contrary, in uraemia 
Kussmaul lays much weight on the beneficial effects of cold packs 
where hot baths produce untoward symptoms (Baruch). 

Antipyretics. — Antipyretics are of little value in scarlet fever, 
and should not be used unless there is some special contraindication 
against hydrotherapy. Antipyretics of the coal-tar series especially 
weaken the heart in the toxaemia which accompanies scarlet fever. 

Heart. — The heart is supported in septic cases with high tempera- 
ture, in the same manner as in other diseases of a toxic nature. 
Alcohol (whiskey) is not given in mild cases. In considering its 
administration the kidneys should be taken into account. We wait 
until the temperature remains persistently high. At the third or 
fourth day a constant temperature of 105° F. (40.5° C.) which 
refuses to abate with treatment calls for the employment of alcohol 
with other remedies. For a child of from two to five years half a 
drachm to a drachm of alcohol every three hours is a sufficient dose. 
Alcohol and digitalis are probably our best cardiac remedies. Caf- 
feine and camphor may also be employed. Strychnine does nor seem 
to do so well in cases in which there is an active myocarditis. 

Throat and Nosc.—lw inflammations oi these passages we simply 



288 THE SPECIFIC INFECTIOUS DISEASES. 

keep the parts sprayed with an alkaline solution in order to remove 
excessive secretion. In this way the patient is made comfortable and 
the inflammation of the fauces kept within bounds. It is not always 
possible to spray the throats of the little ones. If there is nasal 
involvement, the passages may be kept clear by syringing with salt 
solution in the manner as described by Kellogg and in vogue at the 
Minturn Hospital, New York. 

The patient, protected by a rubber sheet, is turned on one side 
with the cheek resting on the edge of a pus basin, and the head is 
lowered slightly by removing the pillow. (Infants are prepared as 
for intubation by wrapping them from the shoulders to the feet in 
a strong sheet fastened firmly at the shoulders, elbows, wrists, knees, 
and ankles.) A fountain or Davidson soft rubber bulb syringe is 
used. The straight tip of the syringe is introduced into the mouth 
in the median line and carried back to the base of the tongue, which 
is held down so as to expose the back of the throat. The solution is 
then directed with considerable force against the pharynx, or the part 
of the throat from which we wish to dislodge the membrane. When 
the mouth is filled, the tube is compressed with the finger, and the 
patient is allowed to expel the solution into the basin. This procedure 
is repeated until the treatment is finished. Strong antiseptic solu- 
tions or solutions of sublimate or peroxide of hydrogen are of little 
use if not harmful. Antitoxin of diphtheria is employed if true 
Loffler diphtheria coexists. In the streptococcic or most common 
form of pseudomembranous inflammation we have no remedy which 
acts directly on the inflammation. Antistreptococcic serum has not 
given encouraging results. 

In those cases of scarlet fever in which there is great obstruction 
of the nasal passages and enlargement of the tonsils, with spreading 
of diphtheritic membrane from the tonsil to the nasal pharynx and 
posterior nares, there is great difficulty in breathing. It is almost 
impossible in some cases to cleanse the nares on account of the accu- 
mulation of secretion and pseudomembrane. The patient lies in a 
semi-soporose state. The lymph-nodes at the angle of the jaw are 
greatly enlarged. This condition of affairs may set in from the very 
onset of the disease. In these cases the problem arises of relieving 
the difficulty of breathing. Any interference in a surgical way with 
the tonsil would be dangerous to the patient at this time. 

Two courses are open to us : We may intube the nostrils with a 
piece of soft-rubber catheter tubing, each nostril being intubed with 
a piece of soft-rubber catheter, extending backward toward the pos- 
terior wall of the nasal pharynx. Nos. 10 to 12 are the most avail- 
able calibres of tubing. The pieces of rubber tubing are secured 
externally with safety-pins, being cut close to the external nares. 



SCARLET FEVER. 289 

Through these tubes the posterior nasal space can be cleansed by 
cautiously allowing some salt solution to run through the rubber 
tubing (Northrup). The relief in some cases is instantaneous; in 
others the amount of secretion is so great as to block up the rubber 
tubing. There is then no other resource but to remove the tubing 
and to instil in each nostril 3 to 5 drops of a 1 : 1000 solution of 
adrenalin chloride three or four times daily. The relief from this 
remedy is very great in some cases. I have seen the breathing re- 
lieved at once. At the same time, owing to the fact that adrenalin 
is a cardiac stimulant, the patient is rather supported as well as 
relieved by this remedy. Its effect should, however, be closely 
watched. We should be very cautious in these cases not to irrigate 
the nostrils either too often or too forcibly, on account of the danger 
of ear complications, but should try every measure before resorting 
to irrigation. Nasal irrigation is carried out in a manner similar to 
that pursued in attacks of true diphtheria in the same situation. 

Lymph-nodes. — The lymph-nodes, especially in the region of the 
angle of the jaw, are, if swollen, treated with local cold applications, 
with inunction of ichthyol or unguentum Crede underneath the cold 
applications. This frequently affords much relief. Unless distinct 
fluctuation exists, we should avoid incision of the lymph-nodes of the 
neck. The author has seen these nodes incised at the beginning of 
the second week in septic cases, with very unsatisfactory results. 
Pus is not found in such cases, but only foci of necrosis, which are 
best left to nature until the patient regains strength. Later in the 
disease such nodes may suppurate and need incision. 

Nephritis. — The treatment of nephritis is elsewhere described in 
detail. The lines of procedure are indicated here. As a prophy- 
lactic against the occurrence of nephritis the early exhibition of 
urotropin in doses of three to five grains, three times daily, is con- 
sidered of great value. Headache, vomiting, and convulsions are 
treated with hot baths, and by the continuous irrigation of hot saline 
solution (Kemp) per rectum. The kidneys are apt to be affected 
from the outset in malignant cases. In these cases the Kemp treat- 
ment with saline enemata is most suitable. With young or intract- 
able children the continuous irrigation of Kemp cannot be carried 
out. In these cases a high rectal enema of normal saline solution is 
given twice daily or more often if necessary. It' genera] anasarca is 
present, the patient is given two warm baths daily; or with aid of 
hot air diaphoresis may be facilitated by wrapping him in a blanket 
which has been moistened with hot water and then wrung dry. Digi- 
1 al is in the form of infusion is iho most efficient remedy, combined 
with moderate doses oi' potassium acetate, tan rate or citrate. Milk 
is the exclusive 4 diet. 

19 



290 THE SPECIFIC INFECTIOUS DISEASES. 

Complete suppression of urine, with blood and all the anatomical 
elements of severe inflammation of the kidney, will sometimes be 
followed by an increased amount of urine. In such cases the treat- 
ment just indicated will not be efficacious. The heart must be sup- 
ported, and watch kept for uremic symptoms. Opium should be 
employed with extreme caution — best not at all in convulsions; 
chloroform inhalations with chloral per rectum are preferable. Saline 
enemata at 108° F. (42.2° C), diuretin, and nitroglycerin are appli- 
cable in those cases in which there is suppression of urine. 

Otitis. — Otitis is sometimes first indicated by spontaneous per- 
foration and purulent discharge. In other cases pain with a sharp 
rise of temperature will indicate inflammation of one or both ears. 
Paracentesis is best performed early, even if only slight redness of 
the drum is present. Later in the disease (fifth or sixth week) both 
ears may continue to discharge profusely, with an evening rise of 
temperature. In some cases the author has noted slight frontal head- 
ache and drowsiness toward evening. There may be only a slight 
redness over the mastoid of one or both ears. It is best not to tem- 
porize in such cases, but to advise opening the mastoid process to 
insure drainage and avoid sinus thrombosis or cerebral abscess. 

' Complications in the lung, such as bronchopneumonia, are treated 
on general lines. The possibility of the occurrence of pleurisy should 
not be lost sight of. Extensive effusions must be aspirated. In all 
forms of pleurisy, even if the amount of fluid is not large, but per- 
sists, with a rise and fall of temperature, a needle should be intro- 
duced into the chest to determine the nature of the fluid. Pus should 
be evacuated from the pleura in the manner directed in the chapter 
on Empyema. 

Joints. — Joint-affections are best treated by immobilizing the 
affected articulations. The patient should be kept quiet, and sodium 
salicylate in liberal doses administered. If this is ineffectual after 
a few days, the joints should be wrapped in cotton moistened with 
oil of wintergreen, and sodium salicylate combined with sodium 
bicarbonate given in very liberal doses (aa grains iv (0.4) for a child 
of three or four years, four times daily). It synovitis occurs and the 
fever continues high, the joint should be aspirated under antiseptic 
precautions, in order to ascertain if pus is present. If this is the 
case, an incision with drainage is the proper remedy. 

Serum Treatment. — The serum treatment of scarlet fever by 
means of a polyvalent streptococcus serum has recently been favor- 
ably reported by Escherich, Moser, Bokai in Europe and Charlton in 
America. The difficulty of preparing such a serum has as yet pre- 
vented its general adoption. 



KOTHELN. 2S>1 

ROTHELN. 

(German Measles; 'Rubella; Trousseau's Eoseola.) 

Epidemics of this disease have been described by Forney, 1784; 
Heirn, 1812; Hildebrand, 1832; and in recent times by Thomas 
Smith and Crozer Griffith. It is an acute infectious disease, con- 
tagious from person to person, through the atmosphere, though not as 
highly so as measles. It may occur in the same person a number of 
times, and may attack those who have had measles. All children 
exposed do not develop the disease. 

Age. — The youngest patient in the author's experience was seven 
weeks old. The affection may occur at any age. The author has 
seen cases in adults. It occurs with the same frequency in both sexes. 

Prodromal Period. — There is a prodromal period, during which 
there may be a slight suffusion of the eyes, with swelling of the con- 
junctival fold at the inner canthus of the eye. In two cases observed 
by the author the lymph-nodes behind the border of the sternomastoid 
muscle were enlarged six days before the appearance of the exan- 
thema. There is no fever or constitutional disturbance. The period 
of incubation is placed by Thomas and Emminghaus at from fifteen 
to twenty days. Just prior to the eruption there are headache, nausea, 
and bronchial irritation (Forcheimer, Emminghaus). 

Symptoms. — Exanthema. — The exanthema resembles that of mea- 
sles so closely that at the outset it is common for physicians to mis- 
take one for the other. It is also similar in that it is first noticed to 
appear faintly around the alse nasi and on the upper lips. The exan- 
thema appears first on the face, at the temporal regions, and on the 
cheeks. It is in some cases preceded by an erythematous blush dif- 
fused over the whole face (Emminghaus), which disappears in a few 
hours, leaving the true exanthema (pre-exanthematic erythema"). 
The exanthema is papular, of a deep rose-red color, and distinctly 
arranged in crescentic outlines. This arrangement of the papules in 
circles and half circles can be made out where the eruption is spread- 
ing. On the face and neck it gives place to the blotchy appearance 
characteristic of measles. As a rule, the eruption remains discrete. 
(Edema of the skin is rarely present. 

The papules have been described as of two varieties — one the size 
of those in measles, and the other punctate (Thomas"). The punctate 
papules have been seen by the author on the upper part of the chest. 
where the eruption is confluent. They are likely to be mistaken in 
these cases for the exanthema of scarlet fever. In some cases of 
Thomas and of the author the punctate papules only were present 
over the whole trunk. There is an absence of the intense dermatitis 
seen in scarlet fever, and the individual roseolar spots have the out- 
line above referred to. 



292 THE SPECIFIC INFECTIOUS DISEASES. 

The exanthema, while fading on the face and chest, spreads slowly 
on the extremities, remaining discrete where it is spreading. It 
remains at its efflorescence on the face and trunk from a few hours to 
a day, when it begins to fade first from the face, and then from the 
trunk. A patient may present a perfectly normal skin twenty-four 
hours after the appearance of the eruption. Evidences of the erup- 
tion may remain on the trunk and skin for two or three days. The 
skin then may present bluish or brownish crescentic spots in place 
of the original exanthema, similar to what is seen in simple erythema. 
Four days after the eruption has appeared the skin in most cases will 
have a normal hue. There is no pigmentation or discoloration as 
in measles. 

Desquamation. — Desquamation is not always apparent. It is 
possible in exceptional cases to see a very slight desquamation on the 
upper part of the thorax or inner aspect of the thighs. 

The Eruption on the Mucous Membranes. — In rotheln the erup- 
tion on the mucous membranes does not resemble the exanthema of 
the skin. There is an eruption in the mouth, but it is not charac- 
teristic. There is a mild injection of the conjunctiva, a redness of 
the fauces, and perhaps a slight cough. Coryza, photophobia, and 
bronchitis are absent. The mild angina and the injection of the con- 
junctiva resemble what is seen in la grippe. Thomas and Emming- 
haus have described an irregular, spotted, streaked appearance, with 
small grayish miliary vesicles, on the soft and the hard palate. Ger- 
hardt has described a spotted hemorrhagic eruption on the palate, and 
Forcheimer an irregular macular rose-red eruption on the soft palate. 
None of these is constant or characteristic of rotheln, but all are 
found in other affections. The buccal mucous membrane, however, 
is absolutely free from eruption of any kind, and in this fact we have 
a valuable diagnostic distinction between this disease and measles. 
In a small percentage of cases a few red stellate spots on the buccal 
mucous membrane have been seen by the author. In no case, how- 
ever, was the measles spot with its bluish-white central speck present. 

Temperature. — The temperature may at the outset be 99.8° F. 
(37.5° C.) in the rectum, and continue at this point throughout the 
disease. It may be 102° F. (38.8° C), rarely higher. The tem- 
perature is highest at the outset when the exanthema appears on the 
face (Fig. 40). It falls rapidly within a few hours by a sort of 
crisis. Meanwhile the eruption may spread to the lower extremities. 

Lymph-nodes. — The author has studied a number of cases with 
especial reference to the lymph-nodes. Before the appearance of the 
eruption the nodes behind the sternomastoid and angles of the jaw 
may be enlarged. At the time of appearance of the exanthema the 
nodes of the axilla, bicipital groove, and groin become enlarged to the 



EOTHJELN. 



293 



size of a bean or larger. The nodes may remain enlarged for weeks 
after the eruption has disappeared. 

Spleen. — The spleen is not enlarged. 

The Genitals. — In one case the injection of the vulvar mucous 
membrane caused temporary dysuria. 

Complications. — Rotheln is such a mild disease that complications 
are rare. 

Prognosis. — The patients recover rapidly. 

Diagnosis. — The diagnosis of rotheln should not present any diffi- 
culties. It is most likely to be confounded with measles, scarlet 
fever, and erythematous eruptions. 

























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24 


24 


20 


22 


20 



Temperature-curve of a case of rotheln in a boy six years of age. Observed 
from the outset. 



The symptoms are much milder, and there is an absence of the 
specific buccal enanthema of measles. Measles does not, as a rule, 
present simultaneous lymph-node enlargements all over the body, such 
as are seen in rotheln. 

Scarlet fever presents a severe dermatitis, which is absent in 
rotheln. There is a marked angina of a progressive type, with high 
temperature. The general enlargement of lymph-nodes is not so 
useful a sign, since in scarlet fever the lymph-nodes of the neck may 
be enlarged at the angle of the jaw, or those in the axillae and in the 
groin may enlarge as the eruption develops. Tn scarlet fever there is 
a characteristic desquamation. 

Erythematous eruptions of the small papular typo may resemhle 
rotheln, but the characteristic crescentic outline of the rotheln roseola 
is absent. 

Treatment.- Isolation need not be rigid. Children are kept in- 
doors in summer until the eruption has disappeared and the teiu- 



294 TEE SPECIFIC INFECTIOUS DISEASES. 

perature is normal. In the winter months the patients are kept 
indoors one week from the onset of the disease. The angina rarely 
requires treatment. 

MEASLES. 

(Rubeola; • Moroilli.) 

Measles is an acute infectious disease distinguished by a charac- 
teristic eruption or exanthema on the skin and enanthema on the 
mucous membrane of the mouth. It is highly contagious. The 
specific agent has not been isolated. Most people are susceptible to 
measles, and suffer from at least one attack. Infants up to the age 
of five months are not as susceptible as at a later period. Newborn 
infants have been infected by the mother, and the foetus has been 
infected in utero. The foetus in such cases may be expelled pre- 
maturely, and at birth is found covered with the exanthema; or, if 
the infection occurs at full term, the foetus may be expelled alive 
covered with the exanthema (Squire). The firstborn only is believed 
by Thomas to be immune for the period mentioned. The disease is 
very infrequent during the first year of life. Bartels calculates the 
occurrence at this time at 5 per cent, of the total number of cases. 
The author has seen measles in infants under five months of age. 
Measles is most frequent between the age of one and Hxe years (Bartels, 
Henoch). It is prevalent in all countries of the globe; climate or 
meteorological conditions seem to have no influence upon its preva- 
lence either endemically or epidemically. 

Measles has a well-defined period of incubation, varying from 
thirteen to fifteen days (Van Panum). In calculating this period 
we include the time which elapses from exposure to the appearance 
of the eruption on the body. It will be seen later that this period 
includes the period of incubation proper, in which absolutely no 
symptoms, not even fever or malaise, are apparent, and the period 
of the enranthema on the mucous membrane. The enanthema, which 
may be accompanied by coryza of mild or severe type, may appear 
from the ninth to the tenth day after exposure, and lasts from three 
to five days. Thus while the coryza may be postponed several days 
or the enanthema may be present for a variable period, the two periods 
together have a duration of from thirteen to fifteen days. I have 
seen the enanthema fully five days before the exanthema, and have 
seen cases of this kind without any manifestations of coryza to sig- 
nalize the onset of the disease. It is erroneous, therefore, to calculate 
the period of incubation from the exposure to the onset of coryza, as 
the latter is variable as to the time of its appearance. 

One attack protects the individual from subsequent attacks. Au- 



MEASLES. 295 

thentic cases of two attacks in the same individual have recently 
been recorded. By this is not meant a recrudescence of the exan- 
thema after it has once faded. This is also known to occur ( Jurgen- 
sen). Experiments have proved that measles is highly contagious 
in the catarrhal stage. Inoculations with the blood (Home) and 
nasal secretions (Mayr) have given positive results. The period of 
greatest contagion extends through the period of the exanthema. It 
diminishes as the exanthema fades, and is thought to disappear grad- 
ually during the period of desquamation. Thus though more general 
in its power to infect, the poison of measles has a shorter period of 
life than that of scarlet fever. The poison of the latter disease may 
retain its power of infection months after the disease has run its 
course. From what has been said, it will be understood that the 
infection of measles takes place in the vast majority of cases in the 
stage of the enanthema (incubation). At this time there may be 
no coryza. 

Infection occurs during the stage of desquamation (Baginsky). 
If ordinary caution is exercised, it is doubtful whether measles is 
ever carried by a healthy individual to a third person as scarlet fever 
is. Baginsky records an epidemic caused in this manner. The 
poison does not adhere to articles of furniture and wearing apparel 
with the same tenacity as that of scarlet fever. 

Symptoms. —The ordinary simple type of measles is that which 
runs its course without any complications or sequelae. There is a 
prodromal period, which includes the period of incubation before the 
appearance of the enanthema on the mucous membrane of the mouth. 
During this period it is well established that there are no clinical 
symptoms whatever — neither fever nor malaise. At the time of the 
appearance of the enanthema on the mucous membrane the patient 
begins to feel slightly ill. The symptoms may be only a headache or 
a slight disturbance of the stomach. The author had noted in some 
cases a rise of a degree or more in temperature toward evening. 
There are at this time slight injection of the eyes and general lassi- 
tude. Coryza is not pronounced. The patient during the first days 
of the enanthema, and by this is meant forty-eight to seventy-two 
hours before the appearance of the exanthema on the skin, presents 
few signs of illness. 

If, guided by the very faint redness at the inner eanthus of the 
eyes, we look into the mouth, a few spots of a very characteristic 
eruption are seen on the buccal mucous membrane. This eruption 
is pathognomonic of the invasion of measles, and will be later de- 
scribed as the enanthema. After forty-eight to seventy-two hours, 
and in some cases a longer period, there are coryza, cough, and con- 
junctivitis. There is a slight febrile movement, varying in intensity 
in different cases. 



296 TEE SPECIFIC INFECTIOUS DISEASES. 

The exanthema now appears, and is first noticed at the temporal 
region of the face and the ahe nasi as a macular rose-red spotted erup- 
tion, which becomes papular later in the course of the disease. The 
face and scalp are now fully covered by the rose-red irregularly shaped 
papules, which next appear in rapid succession on the back of the 
hands, forearms, anterior part of the trunk, back, and lower extremi- 
ties. This order of the appearance of the exanthema is not always 
maintained. In some cases, as pointed out by Rehn, and verified by 
the author, the eruption may first appear on the back. It is, there- 
fore, advisable to examine the patient in a nude state. 

The eruptive stage of measles generally lasts three or four days, 
during which the patient has an exacerbation of all the symptoms of 
the stage of invasion. There are intense photophobia, active coryza, 
and a croupy cough as a result of the invasion of the laryngeal mucous 
membrane by the enanthema. The bronchi are also affected, and 
there are symptoms of acute bronchitis. Even very mild cases of 
measles show laryngeal and bronchial involvement. At this stage 
the exanthema on the skin is general and profuse, and in places con- 
fluent. The patches of healthy skin are crescentic, owing to the pecu- 
liar conformation of the papules. In some mild cases the rash may 
be very diffuse, but in others discrete. In the mildest forms of 
measles the rash closely resembles in the latter respect that seen in 
rotheln. 

The fever reaches its height when the eruption on the skin is fully 
developed. If the mucous membrane is inspected at the height of 
the skin eruption, it will be seen that the enanthema becomes diffuse 
before the eruption of the skin is fully developed. The mucous mem- 
brane of the mouth is diffusely inflamed and studded with bluish- 
white specks which rapidly disappear or desquamate. The eruption 
on the skin persists for three or four days and then begins to fade. 
With disappearance of the eruption the general symptoms abate. 
The fever remits, and the temperature becomes normal by gradual 
morning remissions. The coryza, cough, and photophobia lessen, and 
the patient passes into the convalescent period. Desquamation begins 
when the pinkish hue of the eruption has disappeared. This stage 
continues until the last vestige of pigmented spots on the skin has 
disappeared. As a rule, it is completed two weeks after the exan- 
thema has made its appearance. Desquamation is never absent in 
measles (Crozer Griffith), but it may be difficult to detect its pres- 
ence. The epithelium is shed in the form of branny scales. Desqua- 
mation is best seen on the anterior part of the chest, shoulders, and 
inner surface of the thighs. In uncomplicated cases it is not attended 
by constitutional symptoms. 

The Temperature. — Measles presents no characteristic fever- 



MEASLES. 



207 



curve. The invasion is rarely signalized by a chill. There may be 
a slight sensation of chilliness. The prodromal period before the 
appearance of the enanthema is not marked by fever. The period 
of the enanthema presents a slight temperature with morning remis- 
sions to normal (Fig. 36). When the eruption appears on the skin 
the fever increases, and reaches its height after thirty-six hours, at 
the time of the full development of the eruption. The temperature 
continues high with morning or evening remissions for from one and 
a half to two and a half days, and. then subsides, and disappears in 
from twenty-four to thirty-six hours after desquamation has set in. 
The temperature may reach 104°-105.8° F. (40°-41° C.) without 
complications. During the stage of desquamation the temperature 
is not elevated unless complication exists in the lung or elsewhere 
(Fig. 41). 

Fig. 41. 



DAY OF 


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Uncomplicated measles in a boy of five years. 



I have sketched the type of disease which is not complicated by 
serious affection of the viscera and which has no sequelae. On 
account of variations from the simple type just described, measles 
is one of the most dreaded diseases of infancy and childhood. 

In fatal cases occurring during the first two years of life the lung 
is generally involved (Henoch ). The appearance of the eruption is 
ushered in with a convulsive seizure or a chill. The pneumonia 
appears as the eruption reaches its height, and within two weeks 
either proves fatal or else leaves the patient weakened or the subject 
of an empyema. The infection of the kidneys may be so severe as 
to prove speedily fatal, or there may be severe mastoid disease. On 
the other hand, there are cases of measles of a type so mild as to 
cause little constitutional disturbance. The fever is very mild and 
evanescent, and present only at the outbreak of the eruption, and 



298 THE SPECIFIC INFECTIOUS DISEASES. • 

even at this stage may be so slight as to escape notice. Jiirgensen 
records measles without fever. 

The Enanthema, — This is the eruption which appears on the 
mucous membrane of the mouth. It differs from the exanthema in 
respect to location. The enanthema appears in the mouth from three 
to five days before the appearance of the exanthema. It is accom- 
panied by redness of the pharynx, and of the anterior and posterior 
pillars of the fauces. The soft palate is studded with irregularly 
shaped rose-colored spots or streaks. The spots on the hard palate 
present small whitish, punctate, miliary vesicles. These spots are 
also found on the otherwise normally colored mucous membrane of 
the cheeks and on that opposite the gums of the upper and lower 
molar teeth. They have been described by Flindt in these localities 
and on the palpebral conjunctiva. Filatow has described a desqua- 
mation of the epithelium of the mucous membrane of the lips and 
cheeks, in the form of minute whitish shreds (Slawyk). A complete 
series of studies of the enanthema of measles has been made, and 
there can, therefore, be no doubt of its existence. In 1896 I pub- 
lished a study of the enanthema on the buccal mucous membrane, and 
on the inner surface of the lips. In this study I showed that the 
enanthema on the hard and soft palate so frequently described since 
the publication of Rehn was not peculiar to measles. The spots of 
rose-colored papules or streaks with the superimposed miliary vesicles 
are found in rotheln, scarlet fever, and some cases of simple angina. 
The eruption on the buccal mucous membrane alone, however, pre- 
ceding the appearance of the exanthema on the skin by a period of 
from three to five days, is characteristic of the invasion of measles. 
It is pathognomonic of the disease, and occurs in no other known con- 
ditions. It is almost invariably present, observations having shown 
it to be absent in only a very small percentage of cases (Plate XIV.). 
On looking at the mucous membrane lining the cheeks (buccal) 
in strong sunlight, a very characteristic eruption of irregular stellate 
or round rose-colored spots is seen. In the centre of each spot there 
is a bluish-white speck. This appearance of a bluish-white speck on 
a rose-colored background is pathognomonic of the onset of measles. 
The speck is sometimes so minute that strong sunlight is necessary 
to render it visible. The number of specks at the outset may be less 
than half a dozen. In a short time they become more numerous, and 
the rose-colored spots become confluent, so that there are diffusely red 
patches of buccal mucous membrane studded with bluish-white specks. 
The specks rarely or never become confluent ; their color does not 
resemble that of sprue, nor are they as coarse as sprue accumulations. 
They are seen on the inner surface of the lips, and are sometimes 
well marked on the buccal mucous membrane adjacent to the gums 



PLATE XIV 



FIG. 1. 



FIG. 2. 





FIG. 3. 



FIG. 4. 





The Pathognomonic Sign of Measles i^Koplik's Spots\ 

Fig. 1. The discrete measles spots on the buccal mucous membrane, showing the isolated rose-red 

spot, with the minute bluish-white centre, on the normally colored mucous membrane. 

FlQ. 2. Shows the increased eruption of spots on the mucous membrane of the cheeks ; patches 
pink interspersed among rose-red areas, the latter showing numerous pale bluish-white spots. 

Fig. 3. The appearance of the buccal mucous membrane when the measles spots coalesce and give a 

diffuse redness, with myriads of bluish-white specks. The exanthema is at this time fully developed, 

FlG. I. Aphthous stomatitis sometimes mistaken for measles -pot-. Mucous membrane normal in 
color. Minute yellow point* are surrounded by a red area. Always di-crete. 



MEASLES. 



299 



of the upper molar teeth. If the finger is passed over the miicoufl 
membrane, they are felt to be raised and firmly adherent. They can 
be rubbed off by force or picked off with forceps. As the exanthema 
spreads, the enanthema of the buccal mucous membrane becomes dif- 
fuse. "When the exanthema is at its height and during efflorescence 
the eruption on the mucous membrane begins to lose its character- 
istics. The bluish-white specks are washed away by the buccal secre- 
tions and leave the mucous membrane diffusely reddened and raw. 

Fig. 42. 



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Case of measles observed from the first appearance of the " Koplik spots " to the 
time of the outbreak of the exanthema, a period of fully four days. During this time 
it appears there was a gradually rising curve of temperature without any exanthema 
with a low leucocyte count. 



By referring to the temperature-curve, it will be seen that the 
appearance of the enanthema is accompanied before the outbreak of 
the skin eruption by fever of a low type (Fig, 42). There is also 
at this time a leucopenia ; a diazo reaction appears in the urine at 
the time of the outbreak o\' the exanthema. 



300 THE SPECIFIC INFECTIOUS DISEASES. 

Exanthema. — The exanthema of measles is a characteristic erup- 
tion of rose-colored or purple-colored papules, varying in diameter 
from 1 millimetre to 1 centimetre, the average diameter being 2 milli- 
metres. They are irregularly circular, or longer in one diameter 
than another, or shaped like a half-moon. They arrange themselves 
crescentically. They are at first discrete, but soon become confluent, 
so that large areas of skin are covered. Here and there are areas of 
normally colored skin. The discrete papules have a distinctly cres- 
centic arrangement. This is seen on the thorax and thighs. As a 
rule, the whole face is covered with the eruption, and the skin swollen. 
The eruption spreads from the face and head to the back of the neck, 
throat, upper part of the back, chest, and back of the hands and arms. 
The lower extremities become affected, as well as the palms of the 
hands and soles of the feet. As a rule, the eruption on the skin is 
papular; the papules may show at their summit miliary vesicles. 
They may become confluent and form patches. Hemorrhages may 
occur in and around the papules (Morbilli hemorrhagica). In these 
cases petechia occur in the course of the exanthema, and persist into 
the period of desquamation. They should not be confounded with 
petechial eruptions or purpura, which may appear after the exan- 
thema has run its course. The exanthema in weakly children may 
be limited in its distribution and not characteristic. Henoch believes 
that many cases in which the exanthema does not develop in sequence, 
take a subsequent course which may be severe. If therefore the ex- 
anthema should first appear on the back, instead of the face, and 
spread thence, complications may be expected. Although complica- 
tions occur with eruptions which are diffuse and very general, the 
severity of the eruption is no index as to the severity of the disease. 

When the exanthema fades, it leaves the skin studded with dirty 
brownish-colored spots, which have the arrangement of the original 
exanthema. These pigmented areas gradually fade, and when des- 
quamation is complete they disappear. 

Measles may run its course without the appearance of the exan- 
thema on the face. It may be ill-defined and limited to certain parts 
of the body. It may develop in full intensity and then suddenly fade 
within a few hours. This occurs in cases in which severe disturb- 
ances of the circulation alter the distribution of blood in the skin. 
In these cases there may be a complication of the lungs or heart, but 
the fading of the exanthema is not, as is thought by the laity, pri- 
marily the cause of any affection of the internal organs. 

Complications. — The Nose, Pharynx, and Larynx. — In very young 
infants severe inflammation of the mucous membrane of the nose and 
nasopharynx may lead to difficulties not only in breathing, but also 
in feeding. In these cases membrane rarely develops. If it does 



MEASLES. 301 

appear, it takes the form of a pseud omembranous rhinitis, generally 
of a diphtheroid streptococcic nature. Its course then may be sub- 
acute. The larynx is sometimes severely affected, so that at the 
height of the exanthema the patient is troubled with a harassing, 
croupy cough. In some cases the patient becomes almost aphonic. 
If there is no obstruction to the breathing, this symptom, which causes 
great concern, disappears. The larynx may present a pseudomem- 
branous affection of a streptococcic nature. Gerhardt has shown that 
ulceration of the posterior laryngeal wall may ensue from traumatism 
to the larynx as a result of repeated, fits of coughing. If these ulcera- 
tions cause swelling of the mucous membrane, obstruction to respira- 
tion may result. The bronchitis which is always present in such 
cases may cause obstruction of the finer bronchi. On account of inef- 
ficient respiratory effort atelectasis and pneumonia may result, with 
fatal issue. 

Diphtheria.— Diphtheria may complicate measles. It may pre- 
cede the eruption, or may develop at any time during the attack. In 
all such cases the patient has been exposed to a diphtheritic infection. 
A case in the author's hospital service had recovered from diphtheria 
two weeks previous to the attack of measles. Three days after the 
appearance of the exanthema the conjunctiva became covered with 
true diphtheritic membrane. The larynx then became involved, and 
stenosis set in within twenty-four hours after the appearance of the 
membrane on the conjunctiva. The exanthema in these cases is likely 
to fade rapidly or become hemorrhagic. Diphtheria complicated with 
measles is rapidly fatal, since the trachea and bronchi become involved. 
Fatal pneumonia supervenes. On the other hand, the author has 
seen a croupy cough with dyspnoea, set in three weeks after convales- 
cence from measles. Diphtheria bacilli were found in the pharynx. In 
this case no pseudomembrane on the pharynx was visible. It is not 
always possible to decide in a given case whether there is a simple 
swelling of the mucous membrane of the larynx or a pseudomem- 
branous process. In cases with severe laryngeal symptoms, if no 
membrane is visible, a culture of the secretions of the pharynx should 
be made. The temperature-curve does not aid us. Diphtheria may 
run its course with a low or a high temperature. The pulse is of 
little assistance in making a diagnosis. There is nothing in the 
nature of measles which predisposes toward diphtheritic infection. 

During convalescence persistent hoarseness or aphonia is not infre- 
quently seen without other disturbances. The voire gradually returns 
to the normal. 

Prudden and KTorthrup, in a paper on diphtheria with fatal 
pneumonia, record three cases o( fatal diphtheria complicating mea- 
sles. The diphtheria and subsequent pneumonia were o( the strepto- 



302 TEE SPECIFIC INFECTIOUS DISEASES. 

coccus variety. The three cases formed part of a series of seventeen 
cases of streptococcus diphtheria followed by pneumonia. 

Bronchitis; Bronchopneumonia; Atelectasis. — A very serious 
complication of measles is bronchitis, which may involve the capillary 
bronchi, causing atelectasis and bronchopneumonia. In the stage of 
efflorescence the bronchitis at times becomes severe. There are found 
on auscultation fine crepitant rales in addition to the very coarse 
mucous and sonorous rales. At the end of inspiration a fine crepi- 
tation is heard, similar to that present at the beginning of pneu- 
monia. There is also subcrepitation at the close of expiration. In 
these cases the constitutional symptoms are severe, if large areas of 
lung are involved. The dyspnoea is extreme. Although cyanosis 
may be present, no areas of consolidation are detected on physical 
examination. It is reasonable to infer that in all cases of severe 
inflammation of the smaller bronchi, areas of bronchopneumonia 
exist. Auscultation may reveal areas of lung in which the air enters 
imperfectly. An attack of coughing will open up the bronchi, when 
air again enters these areas (atelectasis). In young infants and 
children this form of bronchitis is a serious complication. As a rule, 
it leads to bronchopneumonia. 

The pneumonia which complicates measles, either in the eruptive 
stage or in the desquamative period, is anatomically usually of the 
bronchopneumonic type, although the lobar form may occur. The 
pneumonia is caused by an invasion of the lung tissue by streptococci 
from the bronchi. A bronchopneumonia may at first be difficult of 
detection. As a rule, however, it involves a lobe of the lung in a 
short time. The lower portions of the lung behind are usually first 
involved, although the upper lobes or middle lobe may in exceptional 
cases be first involved. When consolidation takes place, the area of 
lung involved may be as extensive as in lobar pneumonia. A pneu- 
monic process should be suspected if the temperature in the stage of 
desquamation does not fall to the normal. There is a distinct rise 
of temperature which varies in intensity, and remits in the morning 
to become higher in the evening. The cough becomes troublesome, 
and there is also dyspnoea. In such cases the temperature alone can- 
not be relied upon for a diagnosis. A careful physical examination 
will be of assistance. Under two years of age this form of broncho- 
pneumonia is very fatal. As a rule, pneumonia complicating measles 
terminates, if not in immediate recovery, in a bronchopneumonia 
which persists for weeks. The temperature may fall almost to the 
normal in the morning and in the evening rise a degree or more. In 
addition to the bronchopneumonia there may be pleurisy, with thick- 
ening of the pleura and purulent exudate. In some cases the upper 
lobe of the lung shows signs of unresolved pneumonia for weeks. 



MEASLES. 



303 



Emaciation is progressive. All of these cases are not necessarily 
tuberculous. A tuberculous process may be engrafted on a non- 
tuberculous bronchopneumonia at any time by infection with tubercle 
bacilli. In measles there seems to be a predisposition to invasion of 
the lung by tubercle bacilli through the catarrhal and inflamed mucous 
membrane of the bronchi. We can reasonably hope for recovery in 
many of these cases of simple chronic bronchopneumonia. If tuber- 
culous glands, which have been dormant before the invasion of 
measles exist, they form focal points for the development of tuber- 
culosis of the lungs or meninges. Such cases are fatal. Autopsy 
will reveal recent lesions alongside of old tuberculous foci. 

The frequency of infection with tuberculosis varies in different 
localities. In some epidemics it occurs in 5 per cent, of the cases ; 
in others, 16 per cent, or more are affected (Bartels, Jurgensen). 

Fig. 43. 



DATE 


8 


9 


10 


11 


12 


13 


14 


15 


16 


Fel 
17 


)ru; 
18 


iry 
19 


20 


21 


22 


23 


24 


25 


20 


27 


28 


105° 
104 

103° 

1 102° 
~ 101° 

1 ioo° 

H 99° 

98° 
9T° 
















































M 


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PULSE 


102 


118 


116 


124 


132 


124 


134 


140 


140 


132 


140 


146 


136 


140 


140 


128 


142 


140 


130 


128130 


RESP. 


24 


32 


34 


42 


60 


62 


56 


62 


60 


60 


54 


50 


70 


68 


60 


56 


54 


50 


52 60 | 50 



Measles complicated with endocarditis in a boy six years of age. 



The Heart. — The endocardium is rarely affected in measles. If 
endocarditis does occur, it is usually an intercurrent affection in a 
rheumatic subject. Fig. 43 shows a temperature-curve from a case 
in which rheumatism preceded an attack of measles, and which in 
turn was followed by endocarditis. Myocarditis may be found in 
fatal cases of bronchopneumonia. In bronchopneumonia complicated 
with pleurisy, pericarditis may also be present (Baginsky). 

The Intestines. — In some epidemics diarrhoea is a frequent com- 
plication. The movements are numerous, and watery in character. 
When the large intestine is involved the stools contain blood and 
mucus, and tenesmus is present. The season of the year influences 
the intensity of the infection. In the warm months the diarrhoea 
may be of a severe type. In cases recorded by Henoch and Thomas, 
autopsy showed enlarged Peyer's patches and solitary follicles resem- 
bling those seen in typhoid fever. No cases of ulceration have been 
recorded. »7ii re-en sen is inclined to regard the diarrhoea a result 



301 THE SPECIFIC KFECTIOUS DISEASES. 

of infection of the intestinal mucous membrane. The enanthema 
appears in this locality early in the disease. 

The Kidneys. — In many cases of measles, albumin and a few 
hyaline and epithelial casts are present in the urine. They are the 
result of a parenchymatous inflammation of the kidney, due to the 
poison of the disease. A severe nephritis, such as is common in 
scarlet fever, is rarely seen. Nephritis is apt to occur in the severe 
cases complicated with bronchopneumonia. There may then be 
marked albuminuria, blood, and casts of all kinds in the urine, with 
suppression. On the other hand, nephritis in the stage of desqua- 
mation is uncommon. There is always in such cases suspicion that 
an infection coincident with scarlet fever may have been overlooked 
(Henoch). If diphtheria complicates measles, nephritis is likely to 
be present. 

The Bones and Joints. — The author has seen osteomyelitis with 
suppuration of the joints follow measles. Streptococci were found 
in the pus. In one case bronchopneumonia was an earlier complica- 
tion. These cases are rare. 

Lymph-nodes. — If the inflammation of the throat is severe, the 
lymph-nodes at the angle of the jaw and underneath the body of the 
jaw may be enlarged. Rarely, however, is the adenitis as severe as 
in scarlet fever. The glands or nodes in the axillse, bicipital groove, 
over the internal condyle of the elbow-joint, and in the groin may be 
enlarged to the same extent as in rotheln, as a result of the processes 
taking place in the skin. Severe infection of the gut may cause 
swelling of the mesenteric lymph-nodes, which, if not tuberculous, 
will retrograde after the disease has run its course. 

The Blood. — In measles as distinguished from scarlet fever an 
examination of the blood shows a subnormal number of leucocytes 
or a leucopenia. This condition of the blood is found in the initial 
stage of the disease, and persists well into the period of the exan- 
thema in uncomplicated cases, as is well shown in Fig. 39. 

The Nervous System. — It is rare to see convulsions usher in an 
attack of measles, even of a severe type. In anomalous forms of the 
disease complicated with pneumonia there may be cerebral symptoms 
similar to those seen in the latter affection. There may in some cases 
be a complicating cerebrospinal meningitis with purulent exudate. 
If tuberculosis is present, the meninges may be attacked, as in any 
tuberculous infection. French writers have observed neuritis follow- 
ing measles. 

The Eyes. — Following severe cases of measles, photophobia, spasm 
of the orbicularis, inflammation of the lachrymal duct, conjunctivitis, 
ulcerations of the cornea, and amaurosis may result. Hence, even 
in mild forms of the disease the eyes should be frequently inspected 
(Eversbusch). 



MEASLES. 305 

The Genitals. — The author has seen dysuria in cases in which the 
enanthema affected the mucous membrane of the vulva in girls. 
Henoch records cases of gangrene (noma) of the genital organs. 

The Mouth. — Inasmuch as the mucous membrane of the mouth 
is the seat of an active eruption, stomatitis is likely to be present, 
especially if through carelessness or traumatism the mucous mem- 
brane has become infected with bacteria from without. In such cases 
aphtha? may result. Children in unhygienic surroundings are likely 
to develop noma of the cheek if exposed to the infection. 

Pertussis. — Pertussis is an occasional complication of measles. 
A.s in diphtheritic infection, there must have been exposure to the 
contagion of both pertussis and measles, since etiologically the dis- 
eases have nothing in common. The danger in the coincident occur- 
rence of measles and pertussis is that bronchopneumonia is likely to 
develop, and prove a serious if not fatal complication. 

The Ear. — The external structures of the ear may be affected by 
oedema and swelling. The external auditory canal may become the 
seat of painful swelling and diffuse inflammation. Gangrene of the 
pinna has been noted (Nottingham, Bourdillot). The most common 
affection of the ear is otitis media catarrhalis. Of 33 cases of severe 
complicated measles, Tobeitz found otitis of this variety in 16. The 
frequency of otitis varies with different epidemics. The otitis makes 
its appearance in the period between the seventh and the twenty-sixth 
day following the development of the exanthema. Of 22 fatal cases 
of measles, otitis was found in 19, only 7 of which presented symp- 
toms during life. The great majority of cases of otitis give no pro- 
nounced symptoms and end in resolution. These mild cases are the 
result of the action through the blood of the measles poison on the ear 
structures (hematogenic). The severe eases follow a mixed infec- 
tion through the pharynx and Eustachian tube. In the pus of acute 
or chronic otitis, with or without inflammation of the mastoid, the 
streptococcus, Staphylococcus pyogenes, and pyogenic diplococci have 
been found. The general course of otitis is not so severe as that of 
scarlet fever. In some epidemics the severe and fatal cases are more 
common than in others. 

Sequelae. — Any of the complications named above may pursue a 
chronic course. In this sense only are they sequela?. Chronic 
blepharitis, blennorrhcea, keratitis, otitis, catarrhal inflammation or 
ulceration with stenosis of the larynx, septic retropharyngeal abscess. 
and chronic bronchopneumonia may persist for weeks or months. 

Prognosis. — The prognosis in measles varies with the virulence of 
the epidemic, the resistance of tho individual, and the age oi the 
patient. The idea prevalent a mono- the laity, that measles is a 
comparatively mild affection, is incorrect. In the cases treated in 

20 



306 TEE SPECIFIC INFECTIOUS DISEASES. 

both dispensary and private practice, and at all periods of infancy 
and childhood, the mortality is 8 per cent. (Breyer). The mor- 
tality is greatest during the first year of life, and may vary in 
different epidemics from 10 to 40 per cent. The lowest mortality 
seems to be between the fifth and eighth years — 6 per cent. (Bagin- 
sky). Hospital statistics are of little value to the general practi- 
tioner, as the class of cases treated in institutions give a high mortality- 
rate. The mortality in hospitals may be as high as 30 to 35 per cent. 
(Henoch, Fiirbringer). 

Diagnosis. — The diagnosis will in most cases present few diffi- 
culties if the physician follows a fixed routine in the examination of 
the patient. The mode of onset, the coryza, the enanthema of the 
buccal mucous membrane, and the skin eruption are characteristic. 
If the physician will examine the inner surface of the cheeks and the 
buccal mucous membrane in every seemingly slight indisposition of 
children, he will in certain cases be able to predict an attack of measles 
far in advance of the appearance of the exanthema. In some cases 
the enanthema appears on the buccal mucous membrane before coryza 
is present. The inspection of the buccal mucous membrane thus 
becomes important as a prophylactic measure. Strong sunlight is 
essential for thorough inspection. Although the bluish-white spots 
on the rose-red background may sometimes be seen by artificial light, 
especially electric light, a diagnosis of measles should never be made 
at night. Cases of influenza closely resemble measles at the outset. 
These present the injected conjunctivas, cough, and rose-colored spots 
on the soft and the hard palate seen in measles. In la grippe, how- 
ever, the buccal mucous membrane is pale and presents absolutely no 
eruption. In one of the early grippe epidemics in 'New York the 
children showed an ill-defined roseolar eruption on the surface, but 
the buccal eruption was never present. 

Rotheln. — Rotheln in some cases resembles mild measles so closely 
that the author has often questioned whether so-called cases of mild 
measles without rise of temperature, described by authors, were not 
cases of rotheln. The difficulty in differentiation is increased if 
measles is prevalent at the same time. The absence of the buccal 
eruption is a crucial test. Schmid has also laid stress on this point. 
In some rare cases of rotheln there may be seen an isolated, rose-red 
spot here and there on the buccal mucous membrane, but the bluish- 
white speck in the centre of these spots is never seen as in measles. 

Scarlet Fever. — Scarlet fever may at times closely resemble 
measles, especially in those forms in which the eruption on the face 
is evanescent. In scarlet fever the buccal mucous membrane has a 
normal hue. The author has seen scarlet fever complicated with 
measles. In these cases the scarlet eruption appeared first. Within 



MEASLES. 307 

two or three days there was a general recrudescence of the exanthema, 
with the appearance all over the body of a roseola (the scarlet rash 
had faded somewhat), coryza, and the buccal eruption. In other 
cases the scarlet fever eruption on the back of the hands and forearms 
assumes the blotchy, papular roseolar form of the exanthema of 
measles. The author has seen a case of this kind in which an expert 
entertained the possibility of rotheln or measles. The buccal enan- 
thema was absent. The subsequent course of the case proved the 
diagnosis of scarlet fever to be correct. 

Typhoidal Roseola. — The roseola of typhoid is sometimes so abun- 
dant as to mislead the physician into mistaking it for the eruption 
of measles. Measles complicating typhoid at the end of the second 
week has come under the author's notice. In this case the buccal 
eruption was profuse. 

Drug Eruptions. — Antitoxin and drug eruptions may simulate 
a measles eruption, but the buccal mucous membrane never presents 
the enanthema. 

Syphilitic Roseola. — The roseola of syphilis frequently resembles 
that of measles so closely as to cause uncertainty in the diagnosis. 
Here the conjunctivae may be injected, and there may be a slight 
febrile disturbance (Sobel). The buccal mucous membrane is pale. 
and shows no eruption resembling that seen in measles. 

The diagnosis of measles thus resolves itself into a recognition 
of the disease before and after the appearance of the skin eruption. 
Before the appearance of the eruption there is very little to guide 
us. Cough, coryza, and fever may accompany an influenza. In these 
cases the buccal eruption is of great diagnostic value. After the 
eruption appears, the question narrows itself to the differentiation of 
measles from rotheln or scarlet fever, and the recognition of the 
various forms of erythema, roseola, drug and antitoxin eruptions. 

Prophylaxis.- — As soon as the physician has made the diagnosis of 
measles or suspects its presence, the patient should be isolated from 
other children of the family. Among the poor it is sometimes im- 
possible to do this. The members of the family not directly con- 
cerned in the care of the patient should be denied admittance to the 
sick-room. It is not necessary to cover the door of the room with 
cloths or sheets moistened with disinfectants. The physician before 
entering the room should take off his coat and put on some convenient 
linen gown or bath-robe, so as to completely cover his person. This 
robe should hang outside the door of the room, so as to be easily acces- 
sible. When not in use, it should be hung in the open air. It the 
physician wears a beard, he should wash it after leaving the patient, 
for if the patient coughs in the physician's face, he is likely to carry 
the infection in his beard to the next child visited. Should the 
measles be complicated with diphtheria, extra precaution is necessary. 



308 THE SPECIFIC INFECTIOUS DISEASES. 

Treatment. — General. — A typical mild case of measles needs little 
medicinal treatment. We try to make the patient comfortable. The 
temperature of the room should be about <38°-70° F. (20°-21.1° C), 
if possible. The ventilation should be constant and attained by 
means of opening doors and windows of rooms communicating with 
the sick-room. It is not necessary to darken the room very much; 
in fact, Bartels has shown that light and air are necessary to the 
comfort and well-being of the patient. The author has found that 
the ordinary yellow window-shade, if drawn over the windows, suffi- 
ciently excludes the actinic rays which are irritating to the eyes. 

In a typical case of measles a temperature of 104°-104.5° F. 
(40° C.) may be ignored. It should be remembered that the fever 
continues only during the period of the eruption. With the fading 
of the exanthema the temperature becomes normal. It is only in 
cases in which there is a high temperature with delirium that medi- 
cation is called for. It is not uncommon to see children covered with 
an eruption and with a temperature of 104° F. (40° C.) playing in 
bed with their toys. 

The cough will sometimes need treatment. In such cases I am 
accustomed to prescribe 1U iv (0.25) of paregoric combined with TIX ij 
(0.12) of syrup of ipecacuanha, every three hours. If the patient is 
kept awake by the cough, a small dose of Dover 's powder (grains j 
or ij) (0.06 or 0.12) or codeine (grain ft to i) (0.006 to 0.008) at 
night will be sufficient. If the patient is very restless at night and 
we do not wish to give opiates, grains v (0.3) of trional will quiet a 
child of five years. Some young children can be put to sleep by a 
small dose of phenacetin (grains ij) (0.1). In a mild case, especially 
if there is pruritus or irritation of the skin, there is no objection to 
sponging the patient once a day with water at 100° F. (37.7° C), 
containing some alcohol or a pinch of sodium bicarbonate. 

The food should be light. Milk, broths, and, when the fever has 
defervesced, chicken, soft-boiled eggs, jelly, toasted bread, crackers, 
rusk (Ziuieback), and cereals in attractive form, with cocoa, comprise 
the diet list. Orange-juice or weak lemonade may be given in mod- 
eration. Water-ices may be given, if desired. 

As soon as desquamation has set in, I direct the body to be 
anointed every second day with an ointment of washed benzoinated 
lard combined with 5 per cent, of boric acid. The patient is allowed 
to get out of bed as soon as the temperature has fallen to normal, and 
is permitted to go out of doors three weeks after the outbreak of the 
eruption in the summer and four weeks in the winter months. Be- 
fore mingling with other children, the patient should be thoroughly 
washed with soap. It is not necessary to put an antiseptic in the bath. 

The Treatment of Complications. — Bronchitis; Bronchopneumonia. 



MEASLES. 309 

— A severe inflammation of the finer bronchi is likely to cause as 
much fever, dyspnoea, cough, and restlessness as a primary broncho- 
pneumonia. The temperature then rises and continues elevated — 
104°, even 105° F. (40°-40.5° C.) — with morning remissions. In 
these cases the temperature must be reduced. I never hesitate to 
utilize hydriatic measures. The most convenient mode of applying 
water is by means of compresses moistened with water at 80° F. 
(26.5° C). If the patient reacts well, the compresses may be 
applied at 67° F. (19.4° C.) ; if he becomes cold and cyanosed, at 
105° F. (40° C). These warm compresses are at times very sooth- 
ing, causing the patient to drop into a quiet sleep. It should be 
remembered that the object of applying the compresses is not always 
to reduce temperature rapidly, but rather to stimulate the heart and 
support the patient. Douching the head with ice-cold water, as rec- 
ommended by some, is a very questionable practice. The use of the 
coal-tar antipyretics should be avoided. In lowering the temperature 
they act as depressants. In severe cases of bronchopneumonia aconite 
should not be used to lessen the rapidity of the pulse. Caffeine, cam- 
phor, strychnine, and digitalis in proper doses are more satisfactory. 
If a bronchopneumonia be prolonged into the convalescent stage, we 
should be on the alert for pleuritic effusion. This is especially likely 
to occur if the pneumonia lasts longer than two weeks. In these cases 
the symptoms present are similar to those described under Pleurisy, 
and the treatment is carried out on the same principles. 

Laryngeal Symptoms. — The laryngeal symptoms become harass- 
ing when there is much swelling or slight erosions of the laryngeal 
mucous membrane. In such cases an improvised tent should be 
erected over the crib or bed and filled with steam vapor saturated with 
thymol or turpentine. Older children can be persuaded to breathe 
the vapor generated in an open kettle. If symptoms of stenosis 
appear, it must at once be determined by culture whether a diph- 
theritic process, a streptococcic pseudomembranous formation, or a 
stenosis due to simple catarrhal oedema of the mucous membrane is 
present. 

Diphtheria. — Antitoxin is indicated in diphtheria either of the 
conjunctiva, pharynx, or larynx. A large dose should be given at 
the outset, on account of the virulent nature of this affection as a 
complication of measles. We should not be too ready to intubate 
on the first appearance oi' stenotic symptoms. Many of these eases 
improve. The introduction of a tube into the inflamed larynx in 
measles is not without danger of causing ulcerations of a troublesome 
type after the measles lias run its course. It is well lo follow 
O'Dwyer's advice in such cases withhold the tube as long as dan- 
gerous dyspnoea is absent. The use o( apomorphine, tartar emetic, 



310 TEE SPECIFIC INFECTIOUS DISEASES. 

or turpeth mineral, so popular with continental physicians, to expel 
membrane or secretion, is of doubtful value. 

The Ear. — Otitis should be suspected if there is restlessness and 
an intermittent course of temperature without apparent cause. Older 
children may indicate the seat of pain. In some cases it may be nec- 
essary to incise the tympanic membrane. The procedure affords 
relief from pain, and is without ill effects. Pus or a few drops of 
serum only may be evacuated. 

Diarrhoea. — Diarrhoea requires the same treatment as a primary 
enteric catarrh. 

Eyes, Nose, and Mouth. — The care of the eyes, nose, and mouth 
should be conducted on general lines. If the secretion is excessive, 
the eyes may be bathed once a day with a lukewarm weak saline solu- 
tion. Unless the secretions are excessive, the nostrils should not be 
syringed or douched. If clots of mucus or pseudomembranous shreds 
form in plugs, they may be dislodged once a day by a nasal washing 
with a suitable hand syringe. The mouth should not be washed more 
than once a day. This should be done both for infants who are fed 
artificially and for older children. On account of the great vulner- 
ability of the mucous membrane in this disease the utmost gentleness 
should be exercised lest aphthous ulcerations develop. 

VARICELLA. 

(Cliickenpox ; (Ger.) Windpoclcen.) 

Varicella is an acute infectious disease with a characteristic 
exanthematic eruption. It is distinct from vaccinia or variola, is 
an affection of childhood, occurring before the tenth year, rarely 
later, and is transmitted by direct contact and through the atmos- 
phere. It cannot always be conveyed by inoculation, as is the case 
with vaccinia or variola. It does not protect from vaccinia or variola. 
Varicella, vaccinia, and variola have been observed to attack the same 
patient successively at very short intervals. Few children escape 
after exposure, and one attack does not confer immunity. I have 
seen cases of second attacks. Varicella is an endemic disease, and 
rarely occurs epidemically. 

Incubation. — Varicella has a period of incubation during which 
competent observers have noted no disturbances (Henoch) ; others 
record malaise, coryza, and sore throat. The author is inclined to 
regard the prodromal period as free from symptoms. The period of 
incubation is usually fourteen days, but it may be protracted for 
nineteen days. 

Symptoms. — The symptoms consist of an exanthema, an enan- 
thema, fever, and slight malaise. There may be complications. 



VARICELLA. 311 

Previous to the appearance of the exanthema there may be a slight 
febrile movement and malaise, which in children may pass unnoticed. 
In cases pursuing a normal course, a chill with a marked rise of tem- 
perature may precede the eruption by fully twelve hours. When 
the eruption appears the temperature gradually falls, unless another 
crop of papules appears, when there is another sharp rise of tem- 
perature. Sore throat and slight malaise may herald the eruption. 
There may be, as in measles and in varioloid, an erythema of the 
surface prior to the appearance of the exanthema. 

Exanthema.- — The exanthema consists of an eruption of roseolar 
papules varying in size from that of a pin's head to that of a split 
pea. They first appear on the forehead and face, and spread to the 
trunk. In some cases larger blotches appear, but these are of the 
nature of an erythema, which may precede the eruption of the roseola 
by a few hours. The roseolar papules have a characteristic violet- 
rose tint, are raised above the surface, and are sometimes hard to the 
touch. In a few hours the papule develops on its summit a vesicle, 
which rapidly fills with lymph. These vesicles become tense, and if 
the papule is irregular in shape cover the whole upper surface of 
the papule. In many places the vesicle at the stage of its efflorescence 
presents an umbilication which strongly resembles that seen in the 
vaccinia pock. The contents of the vesicle become cloudy and then 
yellow; the vesicle is surrounded by a dusky pink areola. In the 
course of a day or two the cycle is completed, and the vesicopustule 
begins to desiccate. A reddish-brown scab is developed. 

Many of the roseolar papules do not develop the vesicle and pus- 
tule. While one crop of papules is going through the cycle described 
above, others appear on various parts of the body. It is character- 
istic of varicella to have the surface covered with roseolar papules, 
papules with vesicles, and with pustules, in various stages of devel- 
opment. The papules, vesicles, or pustules may be few or very 
abundant. In some cases after the scab of the vesicle has fallen off 
a distinct scar is left, similar to that seen in vaccination, but much 
smaller ; it may persist for years. The skin between the papules and 
vesicopapules is normal in color. 

The soft palate and sometimes the hard palate may show a few 
isolated papules, vesicles or vesicopustules similar to those seen on the 
cutaneous surf ace (enanthema). Inmost cases there is an angina, an 
injection of the conjunctivae or even an enanthema on the ocular con- 
junctiva (Henoch). Thomas records varicella papules and pustules 
on the nasal and vulvar mucous membrane (Fig, 44), 

The temperature is in many cases little raised above the normal. 
In others it reaches 103° F. (39.4° C.) at the outset of the affection. 
In rare cases 100.5° F. (41.3° C.) has been observed. As soon as 



312 



THE SPECIFIC INFECTIOUS DISEASES. 



the eruption is fully developed the temperature rapidly becomes nor- 
mal. The duration of the fever varies from one to three days. I 
have seen severe cases in which the high temperature persisted fully 
a week. The eruption was in these cases accompanied by secondary 
pustulation. 

Other Symptoms. — Many infants and children show little consti- 
tutional disturbance. In other cases there is lack of appetite with 
excessive irritability. In others, on account of the profuse eruption 
in the vulva and around the nates, there is annoying vesical tenesmus 
and even rectal tenesmus. The latter condition I have seen in a 

































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Varicella temperature-curve showing successive rises due to a new eruption of 
papules and vesicles. Boy aged six years. 



child two and a half years of age, in whom there was a profuse erup- 
tion of vesicles in and around the introitus vaginae, on the nymphse, 
and around the anus. There is in some cases a recrudescence of the 
exanthema in various parts of the body, with rises of temperature. 

Complications.- — Gangrene of the skin with sloughing of large 
areas has been noted by some observers (varicella gangrenosa). The 
conclusion is inevitable that in many of these cases there must have 
been a mixed infection. Erysipelas is also a complication. 

Nephritis. — In many cases there is albumin in the urine to the 
extent of a trace. Henoch has described six cases of varicella compli- 
cated with nephritis on the eighth to the fourteenth day after the 
appearance of the eruption. In these the eruption was profuse and 
accompanied by fever; there was oedema with albumin and casts in 
the urine. One case with fatty liver and moderate hypertrophy and 
dilatation of the left ventricle resulted fatally. Other authors have 



VARICELLA. 



313 



confirmed the observations of Henoch. I have seen slight albumi- 
nuria in some cases of varicella. 

Joint-affections. — I have observed two cases of varicella with 
swelling, pain, and effusion in one or both knee-joints. In neither 
was there suppuration. Both cases retrograded, and in a few days 
the joints became normal. The whole picture simulated what is seen 
in some cases of scarlet fever. There was no endocarditis. 

Otitis. — Otitis may occur as a complication of severe cases. 

Pneumonia. — Pneumonia is an occasional complication (Fig. 45 j. 

Nervous System. — I have recently observed two cases in which 
after the exanthema had run its course, on the tenth or fourteenth 
day of the disease, the patients, both boys, seven and nine years of 
age, developed increasing sopor, with mild hydrocephalus, and paresis 
in all four extremities. In one case there was considerable difficulty 
in swallowing. There was after the first day no temperature above 
100° in the rectum. The symptoms also at times included a restless 



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Varicella bullosa, pneumonia, otitis media purulenta. Female child aged six years. 

delirium. The patients were uneasy and tossed about. These were 
evidently cases of complicating polioencephalitis and were mistaken 
for possible tubercular meningitis. Both cases made a good recovery 
without leaving any paralyses. 

Diagnosis. — The diagnosis of varicella should present few diffi- 
culties. I have seen a number of cases in which the eruption was 
not only very profuse, but the individual varicella vesicles or pus- 
tules were also very large. In these cases there may always arise 
the question of differentiation from the more serious affection, variola 
or varioloid, especially if an epidemic of smallpox is prevalent. The 
diagnosis may even in some rare cases remain in doubt (Jiirgensen), 
In varicella the temperature is lower and the rise shorter in duration 
than in even a mild case of smallpox. In the absence of an epidemic, 
the mildness of constitutional symptoms, discreteness of the varicella 
eruption, and the absence of any oedema oi' the skin between the 
vesicles will aid us. 



314 TEE SPECIFIC INFECTIOUS DISEASES. 

In some cases the eruption of roseola papules on the face and 
trunk has not the characteristic appearance of vesiculation or pustu- 
lation seen in varicella. It is difficult on account of the effects of 
the scratching of the patient to differentiate the eruption from pus- 
tules of a furuncular type. Under such conditions a close inspection 
of the back may result in the discovery of one or two typical varicella 
vesicles. 

Prognosis. — The prognosis is very good in varicella, except in 
neglected cases, in which sepsis may complicate the disease. The 
very rare cases of nephritis (Henoch) should be borne in mind. In 
private practice and in a large ambulatory clinic I have rarely seen 
the severer types of this disease. I agree with Fiirbringer in think- 
ing that such cases raise the question of the possibility of an extra- 
neous infection. 

Treatment. — Though the course of varicella is mild, the cases 
should be isolated like those of any other infectious contagious dis- 
ease. We can never predict the outcome of a number of cases occur- 
ring in epidemic form, although individual cases do well. If there 
are itching and tension, the eruption is covered with 5 per cent, boric 
acid ointment applied without lint. The children are allowed out of 
doors as soon as the temperature has become normal, the scabs of 
the varicella vesicles or pustules have fallen off, and the skin has 
become normal. 

VACCINATION. 

Vaccination is a prophylactic measure against variola practised 
on the human subject. It gives a certain, though not lasting, immu- 
nity against the disease. It is accomplished by inoculating the human 
subject with the contents of the cowpox vesicle. 

Cowpox or vaccinia (vacca, cow) is a specific exanthema which 
occurs on the udder of the milch cow, hence the name. Vaccinia is 
inoculable from animal to animal, and also on the human subject. 
It occurs only at the point of inoculation. 

Successful vaccination gives the human subject almost certain 
protection for a long time against vaccinia or cowpox and variola or 
smallpox. 

The essential cause of vaccinia in animals and the human subject has been 
described by Guarnieri and Kurlow as vaccine corpuscles. These are found in the 
vaccine vesicle and pustule. They are peculiar, finely punctate, amoebic masses of 
protoplasm, showing vacuoles. Loudon and Salmon, on the other hand, deny any 
specific properties to these corpuscles. They think they are simply degenerated 
leucocytes, and are seen in other simple forms of inflammation. 

History. — Edward Jenner (1749-1823) was the first to establish 
the doctrine of vaccination on scientific experimental data. He was 



VACCINATION. 610 

the first to use humanized vaccine — that is to say, to inoculate the 
human subject with lymph from a cowpox vesicle, and then to utilize 
the lymph of the vesicle in the human subject to inoculate others. 
This method has been abandoned. To-day the lymph used is obtained 
directly from the animal. The lymph is, as a rule, inoculated from 
animal to animal for several generations. It is just as effective as 
the lymph of the first animal of the series inoculated. It is called 
animal lymph or vaccine. The disadvantages of using humanized 
vaccine are many. First, there is a natural reluctance among some 
people to vaccinate their children with lymph obtained from the 
human subject. Apart from the popular belief in the transmission 
of tuberculosis, scrofula, and other forms of disease in this way, 
it is not always possible to exclude an infection, such as syphilis. 
The animal lymph can be controlled in its manufacture and produced 
with all scientific precautions. Animal lymph and human lymph do 
not differ in the power to confer immunity against variola. The 
animal lymph should be obtained from the healthy animal in the 
vesicular stage of the eruption; this is the fourth or fifth day of 
cowpox. It is preserved by mixing it with three or four times its 
bulk of glycerin. It may be put up for use on quills or ivory slips 
in a dry state or in small capillary tubes in the liquid condition. 
The so-called vaccine pulp, made up of the contents of the vesicle 
and its epidermal covering, and preserved in glycerin, is not used in 
this country. 

Age at which to Vaccinate. — Every infant child should be vacci- 
nated. There is no contraindication except some acute or chronic 
illness. Even the hemorrhagic diathesis is no contraindication. 
Vaccination is best done between the fourth and the sixth month, 
before teething has begun (Zimmerman). In an emergency, such as 
the presence of an epidemic of smallpox, the newly born infant may 
be vaccinated. 

Method. — Boys are vaccinated on the left arm; girls, for esthetic 
reasons, may be vaccinated on the thigh or calf of the leg instead. 
The outer surface of the arm, at about the insertion of the deltoid 
in the humerus, is usually selected. The skin is carefully cleansed 
with soap and water, washed with alcohol, and dried. With a clean 
sewing-needle the skin is scarified three or four times in one direc- 
tion, and at right angles to the first scarifications. We should not 
cause bleeding, but only expose a raw surface. The scarified area 
should be about one-eighth of an inch square. The lymph is now 
rubbed on the scarified area. If quills are used, the vaccine on the 
quill is moistened with a drop of distilled water before inoculation. 
Scarifying large areas is likely to cause excessively Large pustules. 
with subsequent severe inflammatory reaction. On the other hand. 



316 TEE SPECIFIC INFECTIOUS DISEASES. 

a small area of scarification may give a very large pustule. In other 
words, the size of the vaccine pustule does not always depend upon 
the size of the area of scarification. A mixed infection will give a 
severe reaction with a very small area of scarification. 

Lymph to Use. — Either the liquid or the dry lymph may be used. 
Both are reliable if recently prepared. If the lymph is not fresh, or 
there is carelessness in its use, the vaccination will be a failure. 

Course. — The great majority of vaccinations are quite uniform in 
history. There is an incubation period, during which the wound 
heals. There are absolutely no symptoms. This period usually lasts 
three days, sometimes only two, and may be prolonged to four or six 
days. After this period there is the eruptive stage, ushered in by 
the formation of flat rose-red papules at the points of scarification. 
The papules are either oval or irregularly long. On the fifth day a 
vesicle appears in the centre of the papule and spreads to the periph- 
ery. On the sixth day the vesicle takes up the whole papule, has a 
pearly lustre at the surface, and presents a central umbilication 
(Jenner's vesicles). The seventh day is the day of efflorescence; the 
vesicle is filled and tense with lymph, has a rose-red areola and a 
hypersemic zone outside this areola; there are itching and tension. 
On the eighth day the contents of the vesicle become slightly cloudy. 
On the ninth day the suppuration is pronounced, and on the tenth 
day the suppuration, swelling, and inflammatory reaction are at their 
height. At the end of the tenth day there is a retrogression of all 
the symptoms. The vaccine pustule becomes less angry looking and 
the inflammatory reaction subsides. A crust forms which may 
become dry, hard, and fall off, leaving a scar beneath. This takes, 
as a rule, from ten to fourteen days (Plate XV.). 

Fever in. some cases begins on the fifth day after vaccination. It 
may be slight and reach its height between the eighth and the tenth 
day. There may at this time be slight digestive disturbances, such 
as vomiting or greenish movements. 

The areola around the vaccine pustule may spread so as to involve 
most of the upper part of the arm, or the inflammatory reaction may 
spread over the entire arm, and sometimes over the back. There may 
be enlargement of the lymph-nodes in the axillae. These lymph-nodes 
may suppurate. If there has been no mixed infection, they retro- 
grade with the pustule. 

Complications. — Complications occur according to Sobel in 14 per 
cent, of vaccinations, and are the result of traumatism of the pustule, 
mixed infection (that is, the presence of impurities, such as strepto- 
cocci or staphylococci in the lymph), lack of cleanliness at the time 
of maturation of the pustule, and retention of pus in a dressing. The 
most common complication is an exceedingly severe reaction, with an 



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VACCINATION 317 

extensive necrosis of tissue. This may affect the fasciae or muscular 
layers, causing large loss of tissue. Among the rarer complications 
of vaccination is a true septic infection. In these cases there is a 
history of mismanagement of the pustule, such as traumatism or the 
compression of the arm by a bandage. Infection which manifests 
itself in a remittent febrile curve occurs. In one case which came 
under my notice a few pus-corpuscles appeared in the urine, the elbow- 
joint and other joints became painful and swollen, and suppuration 
in the joints resulted. These cases are fatal. There is a true osteo- 
myelitis of the heads of the bones, with formation of pus in the joints. 
In other cases the child may by scratching inoculate itself elsewhere, 
either on the arms or even lips and eyelids; the latter condition has 
come to my notice. It forms a very painful and severe complica- 
tion. Erysipelas may set in early or late in the history of the vacci- 
nation. It may spread down the arm and forearm on the trunk and 
may endanger the life of the patient. In other cases there may be 
suppuration of lymph-nodes. In susceptible subjects a rebellious 
eczema may appear as a direct sequence of the vaccination. 

Among the complications may be mentioned axillary adenitis, 
hemorrhage into the pock (trauma), exuberant granulations, and 
keloid of the scar. Rosenau found that the dry points contain more 
bacteria than glycerinized vaccine. All vaccine contains pus-organ- 
isms. He thinks that properly prepared glycerin lymph is to be 
preferred to dry points. The same investigator examined a large 
number of samples of commercial vaccine and failed to find tetanus 
germs in them. It seems more likely that carelessness in dressing or 
handling, or faulty technique in performing the operation has been 
the means of introducing tetanus-spores, rather than that these should 
be present in the vaccine virus. 

Generalized Vaccinia. — This is a general eruption of vaccine pus- 
tules, which in rare cases appears from the third to the seventh day 
over the whole trunk and extremities. It is really a generalized 
cowpox, similar to the generalized eruption in the exanthema. 
D'Espine and Jeandin describe cases in which there can be no doubt 
of the absence of infection of the surface by the nails or otherwise. 
The prognosis in these cases is good ; there are no severe symptoms. 
and the fever is slight. 

Vaccination Eruptions, — The eruptions which follow vaccinal ion 
or occur while the pustule is still in course of development are of 
interest. Sobel has made an exhaustive study o( those eruptions. 
Two per cent, of the vaccinations are followed by more or loss gen- 
eralized eruptions. They appear while the local site of the vacci- 
nation is open or as late as eighl weeks after the primary inoculation, 
hut most often between the ninth and the fourteenth dav after iiuvu- 



318 THE SPECIFIC INFECTIOUS DISEASES. 

lation. They have no relation to the size or severity of the local 
pustule, which may be normal. Among the types of eruptions are 
the erythematous, urticarial, papular, vesicular, pustular, morbilli- 
form, bullous, pemphigoid, and scarlatiniform. Auto-inoculation by 
scratching generally occurs an inch or two from the original site, but 
it may occur elsewhere, as on the eyelid or conjunctiva. The most 
common type of generalized eruption is undoubtedly the urticarial in 
its various forms. These include wheals, papules, bullae and vesico- 
papules. The morbilliform are easily differentiated by the absence 
of fever and coryza and other signs of measles. The scarlatinal forms 
cause great uneasiness and elevation of temperature. These cases 
should be observed for urinary complications and subsequent desqua- 
mation, in order to exclude scarlet fever. Among the rarer types 
are the ecthymatous eruptions. 

Management. — The management of a normal case of vaccination 
is important. We should protect the vesicle from traumatism by 
means of some simple contrivance, such as a shield. If the areola is 
angry looking and the redness and swelling severe, we may paint it 
once a day with compound tincture of benzoin. This is very soothing 
and protects the surface from friction. If complications occur, they 
should be treated on surgical principles. Above all, there should be 
no retention of pus by the dressing. Dressings which seal the 
vaccine pustule hermetically from the air cause retention, and are 
therefore dangerous. Sepsis as described above is not the result of 
vaccination, but of subsequent mismanagement. 

Revaccination. — Vaccination should be repeated after the lapse 
of ten years, and every five years thereafter. During an epidemic, 
every one who has not been revaccinated should be vaccinated. Im- 
munity to variola diminishes as we reach the termination of the first 
decade after the first vaccination. If the revaccination runs a typical 
course identical with that of the original vaccination, immunity is 
generally lasting. 

OTHER SPECIFIC INFECTIOUS DISEASES. 

TYPHOID FEVER. 

(Abdominal Typhus; Ileotyphus.) 

Occurrence. — Of 222 cases of typhoid fever in my hospital service, 
122 were of the male and 100 of the female sex. In 8 the age was 
under 2 years, the youngest being 13 months; in 42 between 2 and 
5 years of age; and 97 between the 5th and 10th years; and the 
remaining 75 were among children up to the 14th year of life. Thus 



TYPHOID FEVER. 319 

20 per cent, of the patients were below the fifth year of age. It may 
be said that all these cases were diagnosed by modern methods, includ- 
ing the Widal agglutination test. 

Typhoid Fever and Pregnancy. — According to Etienne, quoted 
by Morse, the foetus in utero is born prematurely in 70 per cent, of 
the cases of typhoid fever in the mother. The causes of the abortion 
are much the same as those which obtain in pregnant women suffer- 
ing from any infectious disease. The high temperature, the toxins 
in the circulation of the mother, and the death of the foetus, all con- 
tribute to cause miscarriage. Of 12 abortions, 9 were stillbirths, 2 
lived four and 1 five days. 

Foetal Typhoid. — There are two sets of cases which prove that 
typhoid fever can be transmitted from the mother to the foetus : First, 
those in which the mother, having been infected with typhoid fever, 
expels a foetus which may have lived some hours after birth and in 
whose organs the typhoid bacillus has been found, such as the cases 
of P. Ernst, Giglio, Lynch, and others. The second set of cases are 
those in which the blood and fluids of the foetus give the Widal reac- 
tion with bacillosis. Such is the case of Foster and Ballantyne. 
The mother of this foetus died of typhoid fever shortly after deliv- 
ery. The stomach contents and the serum of the peritoneal cavity 
gave a Widal reaction. The bacillus was found in the kidney, spleen, 
and intestinal contents, but not in the blood. 

Griffith's case was that of an infant apparently healthy, though 
jaundiced, at birth. When seven weeks old the blood of this infant 
gave the agglutination reaction. It is possible that in this case the 
agglutinating substance passed from the mother to the foetus during 
the pregnancy without causing typhoid fever in the foetus. Thus, 
the presence of the agglutination reaction is no proof of typhoid fever, 
as it may be transmitted through the placenta, and the foetus thus 
escape typhoid fever (Ballantyne). 

The anatomical changes found in the foetus affected by typhoid 
fever are not identical with those seen in the adult. This is due to 
the fact that the infection of the foetus is hematogenous, which ex- 
plains the high foetal mortality. The spleen is sometimes though 
not always enlarged. The changes in the gut are not characteristic, 
being confined to a few enlarged follicles. The liver may be enlarged, 
and the kidney may show hemorrhages. 

Infantile Typhoid. — It has recently been contended that typhoid 
fever is rare in the infant or the child under two years of age. With 
the improved methods of laboratory diagnosis of typhoid fever we 
may shortly be in a position to determine the relative frequency of 
the disease in the newborn and the young infant. Typhoid fever 
certainly occurs under the age of two years. As Cro/.er Griffith has 



320 THE SPECIFIC INFECTIOUS DISEASES. 

pointed out, we should think of the possibility of its presence in 
every case of continued remittent fever of the nursling not to be 
explained on other grounds. Of 331 cases, 9 under two years of age 
were diagnosed by Henoch as typhoid fever. Among others who 
report cases are Ollivier, Noyes, Northrup, and Bell. I have seen 
8 cases under two years. One was in a bottle-fed infant which had 
so-called typhoid sepsis with meningitis and pyelitis. In this case 
there was typhoid bacillosis of the blood and all organs without intes- 
tinal lesions. In another case the infant was on the breast, the 
mother having typhoid fever. Blackader, in a recent series of 100 
cases, met 4 under two years of age. Gerhardt reports a case in an 
infant twenty-five days old, and Blumer 1 in an infant five days old. 
These cases may be regarded as either congenital or post-natal typhoid. 

Morbid Anatomy. — It has been stated that when the foetus in utero 
is affected with typhoid fever the process is in the nature of a hsema- 
togenous infection, and that there are few if any characteristic ana- 
tomical changes. In young infants and children the changes in the 
gut so characteristic of adult cases are not always seen in their full 
development. The solitary follicles and Peyer's patches are enlarged, 
but ulcerations are seen only here and there, and seldom lead to per- 
foration (Monti). In a case of my own the typhoid bacilli were 
found in the blood and various organs, but there were no intestinal 
lesions. On the other hand, in older children the changes in the gut 
closely resemble those of the adult, as has been shown by Henoch. 
The mesenteric lymph-nodes, especially those in the vicinity of the 
ileocecal valve, are enlarged. The remaining changes resemble those 
seen in the adult subject. 

Symptoms. — The invasion of the disease in young children is 
rarely with a, chill. More frequently there are indefinite chilly sen- 
sations and mild general malaise. There are headache, pains in the 
limbs, vertigo, and in many cases vomiting. The symptoms of the 
period of invasion are so very indefinite in infants and very young 
children that cases sometimes escape diagnosis. 

In other cases, after a few days of malaise the cerebral symptoms 
become marked. The headache is augmented by delirium at night, 
especially in older children, and stupor is present. In younger chil- 
dren the period of invasion may simulate a pneumonia. In fact, 
these cases begin as pneumonia, and it is only on careful considera- 
tion of the clinical symptoms — the predominance in a few cases of 
cerebral symptoms or the enlarged spleen, and the presence of roseola 
later on, with the elevation of temperature — that we are led to think 
of typhoid fever. 

In some of these pneumonic cases there are none of the charac- 
teristic features of typhoid. There is no roseola, no splenic enlarge- 



TYPHOID FEVER. 321 

ment, no epistaxis, but there may be diarrhoea. During an epidemic 
only the systematic examination of the blood for the Widal aggluti- 
nation reaction will reveal these cases. Such a case is the following: 
A child, five years of age, was admitted to my hospital service with 
an indefinite previous history. Temperature 104.6° F. (40.3° C), 
pulse 140, and respirations 30. There was apathy, also a broncho- 
pneumonia in the upper lobe of the left lung. This case gave a very 
positive Widal reaction early in the disease. The spleen became pal- 
pable four days after admission. In another case, of a child four 
years of age, signs of a lobar pneumonia of the upper lobe of the left 
lung were present without any roseola, enlarged spleen, diarrhoea, or 
abdominal symptoms. On the fifth day of the disease the Widal 
reaction became positive in a dilution of 1 : 50. This child died on 
the sixth day of the disease, with increasing signs of pneumonia and 
a positive Widal reaction of 1 : 350. 

Many of these cases of typhoid fever in older children become 
comatose after the first week. Such a case was admitted to my 
wards. The onset was with headache and fever. There was no vom- 
iting, epistaxis, or chill. The child became unconscious, with a tem- 
perature of 106° F. (41.1° C), rigidity of the muscles of the neck, 
increased reflexes, ankle-clonus, Kernig's symptom, and enlarged 
spleen. This case gave a positive reaction to the Widal test, and 
lumbar puncture failed to reveal anything characteristic in the fluid 
withdrawn. 

The invasion is not characteristic in infants. In exceptional 
cases (Blackader) a convulsion is the first symptom noted. In some 
cases there may be a simple continued fever, with diarrhoea, without 
other symptoms. In a case reported by Crozer Griffith the roseola 
and the enlarged spleen were present. 

The subsequent history of a case varies with the character of the 
infection. In the forms which have a slow, gradual onset the chil- 
dren remain for a time in good physical condition. During the first 
week the sensorium is clear, the tongue is coated, and the face color 
is good; the spleen may be readily palpable, the roseola appears, and 
there may be diarrhoea or constipation. In some cases the iliac ten- 
derness is marked; in others absent. It may not be possible to deter- 
mine the presence of ileocecal tenderness in young children. The 
symptoms after the first week may be augmented by delirium at 
night; in older children this delirium, which has much the same 
character as in the adult, is also presenl during the day. Children 
from five to seven years of age are more likely lo have the quiet form 
of delirium, while older children are noisy and try to gel our of bed. 

The course of pneumonic cases is noteworthy. Resolution is 
tardy in those cases which recover. To the symptoms of pneumonia 

21 



322 



THE SPECIFIC INFECTIOUS DISEASES. 



are added after a time those of typhoid fever — roseola and enlarged 
spleen. The temperature-curve is not characteristic, and resembles 
that of the sustained remittent type (Fig. 46). In some cases 
pleurisy may be present. 

In the newly born infant to whom the fever has been conveyed in 
utero the picture of the disease is unlike that seen in older infants 
and children. The symptoms resemble those of sepsis of the new- 
born. Thus in the case published by Blumer the first symptom of the 
disease was an uncontrollable hemorrhage from the vagina. Before 
death this was supplemented by hemorrhages into the skin and from 
the gums. 

The cases of typhoid fever in infancy thus far recorded by Morse, 























































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Typhoid fever which began as a lobar pneumonia in a girl four years of age. Consoli- 
dation of the lower lobe of the left lung ; death on the tenth day of the disease. 



Crozer Griffith, Blackader, and the author, may be divided into two 
classes : those in which there is a mild diarrhoea with distention of the 
abdomen, roseola, and enlarged spleen ; and those which present cere- 
bral symptoms. The latter develop coma. In one of my cases there 
were meningitism, a distended abdomen, rose spots, and enlarged 
spleen. In both forms there are severe and mild types. Cases in 
which the temperature rarely rises about 104° F. (40° C.) recover, 
while those with a higher temperature may be fatal. 

Roseola. — In children, as in the adult, the roseolar papules are 
seldom absent. In some cases their number is large, while in others 
they are few and widely scattered over the surface. They may 
appear in successive crops, and reappear in the relapse. Occasion- 
ally the roseola is preceded by a diffuse erythema closely resembling 
the scarlet fever eruption. The roseola may, as in the adult, appear 



TYPHOID FEVER. 



on the third, fifth, or tenth day, and may 
end of the second week, after which it 
gradually fades, leaving a pigmented 
area. The eruption is sometimes so 
profuse as to resemble the eruption of 
typhus. It may be profuse in cases 
in which the cerebral symptoms are 
marked. I have seen typhoid fever 
with severe cerebral symptoms, but with 
an eruption very sparse or entirely ab- 
sent at the height of the disease. In 
severe delirious cases, hemorrhagic areas 
appear on the bony prominence of the 
shoulders and extremities. Petechia? 
are common. In protracted cases ex- 
tensive purpuric areas appear on the 
abdomen. These hemorrhagic cases are 
not necessarily fatal. 

Enlarged Spleen. — The enlarged 
spleen is the most common physical sign. 
At the outset of the disease it is not 
always easy to palpate the spleen. This 
is especially true of younger children. 
The enlarged spleen is present not only 
in older children, but also in cases of 
foetal typhoid fever. I have seen the 
enlargement persist for weeks after con- 
valescence. In one case the spleen could 
be distinctly felt below the border of the 
ribs for a long time after recovery. 

In some forms of relapse the spleen 
enlarges after having diminished to 
the normal size. Cases in which the 
spleen remains enlarged a long time are 
likely to have slight rises of tempera- 
ture of short duration. Typical relapses 
without enlargement of the spleen may 
occur. The fact that the spleen con- 
tinues enlarged after the temperature 
has become normal does not always indi- 
cate the approach of a relapse. 

Temperature. — An elevation of tem- 
perature in young children is usually 



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324 THE SPECIFIC INFECTIOUS DISEASES. 

not noticed by those about the child during the first eight days. 
Children rarely complain of slight malaise, and a rise of a degree 
or even more above the normal may escape notice ; as a result, the 
impression is prevalent that the temperature during the first week 
does not follow the typical curve. The cases which I have observed 
sufficiently early, and which were not complicated with pneumonia, 
showed during the first week the gradual rise seen in the adult (Fig. 
47). This gradual daily rise of temperature is also seen in relapses. 
On each day the temperature at its highest point is higher than on the 
previous day. 

After the first week the temperature is likely to show a remittent 
curve with a sustained maximum point. After the second week the 
temperature may remit, gradually falling, or intermit ; frequently it 
remains high for weeks, with daily remissions. By the end of the 
second week it reaches 104° to 105° F. (40° to 40.5° C.) at its 
highest. In the course of the third, fourth, and fifth weeks it may 
range a degree lower, with remissions to 101° F. (38.3° C), not 
reaching the normal. If the case is protracted, the temperature may 
persist into the sixth week, running up as high as 106° F. (41.1° 
C), falling fully five degrees twice daily. In one case the tempera- 
ture did not become normal until the eighth week. Even at this late 
period there may be relapses. In many cases the temperature falls 
to the normal after six or seven weeks, or becomes subnormal, and 
then after an interval of a few days or a week rises and fluctuates a 
degree or more above the normal. This continues for a few clays, 
the temperature remitting to the normal or near the normal. These 
post-typhoidal fluctuations are sometimes mistaken for relapses. 
They are rather to be attributed to inanition, or are the result of 
slight absorption from the gut. In a large number of cases the first 
sign of convalescence is a subnormal temperature. On the other 
hand, the temperature may be subnormal for a week or more and 
relapse follow (Fig. 49). 

It may be said that as a rule the first week of typhoid fever in 
children shows a gradual rise of temperature. The subsequent tem- 
perature is sustained, remitting two or more times daily. This curve 
may last one, two, or more weeks. In other words, there is no charac- 
teristic temperature-curve. In relapses the temperature rises grad- 
ually from day to day. Among the causes which may give rise to a 
slight temporary elevation of temperature is constipation. A lobar 
pneumonia or a bronchopneumonia will cause a persistence of the 
high temperature, as will also other conditions, such as otitis. 

The inverted type of temperature-curve is described by Henoch. 
The morning temperature is higher than the evening, or there may 
be a rise at 3 a m. or 6 a. m., a fall in the forenoon, with a rise again 



TYPHOID FEVER 



oo: 



at noon, and a fall toward evening. Such a curve may be followed 
within a day or two by the usual fall in the morning and rise toward 
evening. These fluctuations occur at the height and at the decline 
of the disease. 

Hemorrhages. — Hemorrhages from the bowel are not so common 
in children as in the adult. I have seen persistent hemorrhages in 
only 8 out of 222 cases. In one case there was post-typhoidal ulcer- 
ative colitis. The bowels may be constipated, normal, or diarrheal. 
The number of stools varies. In the majority of cases diarrhoea is 
absent. In some the temperature in convalescence may rise a degree 
or more for a day or two. In these cases there may be fecal accumu- 
lation due to incomplete evacuation of the gut. 

Fig. 48. 



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Typhoid fever of short duration in a boy six years of age. 

Pain. — Sensitiveness in the ileocecal region is very difficult to 
determine in young children. In older children it is sometimes 
marked, and indicates ulcerative processes in that region or in the 
neighborhood of the appendix. 

Pain as a symptom in typhoid fever in the adult occurs in two- 
fifths of the cases observed by McCrae. In childhood it is not as 
common a symptom, inasmuch as young children are not apt to com- 
plain of pain. It is observed, however, though the exact percentage 
of cases cannot be stated, on account of the peculiarity of the subjects 
dealt with. In the adult abdominal pain in the course of typhoid 
fever is present in complicating pleurisy and pneumonia; or it may 
be due to a distended bladder, the ingestion of solid food, vomiting, 
frccal impaction, diarrhoea, appendicitis, peritonitis, cholecystitis, 
abscess of the liver, phlebitis of the abdominal veins, and hemorrhage. 

In childhood some of these conditions may be present, accom- 
panied by abdominal pain. In the cases observed by the author 
cholecystitis, appendicitis, perforating ulcers, peritonitis, impaction 
offices, and vomiting could be fixed on as a causal factor in the pro- 
duction of the pain. Tain not due to perforation, appendicitis or 



326 THE SPECIFIC INFECTIOUS DISEASES. 

colecystitis, as a rule, is general in its location. It may be accom- 
panied by meteorisra, or may be present with a retracted abdomen. 
I have seen it in some cases preceded by vomiting; in other cases no 
such symptom was present. In childhood it is particularly notice- 
able that pain not due to perforation is unaccompanied by a rise 
of pulse, and certainly not by a rise of temperature. I have seen very 
severe abdominal pain, necessitating the administration of opiates, 
without the least disturbance of the pulse, respiration, or temperature. 
This latter condition is apt to occur in nervous, hypercesthetic chil- 
dren. The pain due to perforation will be described elsewhere. I 
have seen one case where intense pain was caused by a distended gall- 
bladder with cholecystitis, the diagnosis being confirmed at the oper- 
ating table. In this case the pain was distinctly localized, and there 
was temperature due to the hepatic condition. 

Otitis. — Otitis is not uncommon. I have seen several cases. 

Mastoiditis. — I have observed mastoiditis in 11 cases, 1 of which 
resulted fatally in the second week of the disease. 

Parotitis. — I observed parotitis in 4 cases. 

Tongue. — The tongue of children with typhoid fever resembles 
that of the adult. It is at first coated, and is protruded in a tremu- 
lous manner; subsequently the epithelium is thrown off and the 
papillae become prominent. In some cases the tongue resembles the 
so-called strawberry tongue seen in scarlet fever. At the height of 
the disease it may become dry and fissured, and sordes may collect 
on the teeth. The lips become fissured and bleed easily. 

Nervous Symptoms. — The nervous symptoms of older children 
resemble those of the adult. With younger children sopor is the rule 
and delirium is infrequent. Melancholia or depression is occasionally 
met with in convalescence, usually in girls of hysterical temperament. 

The Heart. — In a recent epidemic of typhoid many cases showed 
systolic apex-murmurs. These murmurs were loudest over the base, 
close to the sternum, or over the pulmonary orifice. Such murmurs 
are myocarditic. In one case there was a loud musical systolic 
murmur heard over the apex of the heart. It was also heard at the 
base of the heart. The murmur appeared early in the third week. 
There was also a pleuropericardial friction-sound. Post-mortem ex- 
amination revealed myocarditis and pleuropericardial adhesion. 

The Lungs. — The occurrence of lobar or bronchopneumonia late 
in the course of typhoid is serious. At this time the patient's powers 
of resistance are greatly diminished. Especially grave are the cases 
which show a sustained high temperature for two or three weeks, and 
then develop pneumonia. If with the pneumonia there are extensive 
hemorrhages under the skin at the situation of the bony prominences, 
the outlook is grave. In such a case I have seen a pneumonia involve 
the whole lobe of the lung in consolidation within a few hours. 



TYPHOID FEVER. 



327 



The Blood. — In children, as in the adult 
cells diminishes, and reaches the lowest point 
period. The hemoglobin also is 
diminished. The leucocytes are di- 
minished from the outset until con- 
valescence, but increase after it is 
established. In one of my cases 
their number fell to 3500, and then 
rose to 12,400. In a case compli- 
cated with extensive ulceration in 
the gut and bronchopneumonia they 
numbered 30,000. In fatal cases 
complicated with lobar pneumonia 
I have found them as low as 4500. 
According to Thayer, the polynu- 
clear neutrophiles steadily diminish 
as convalescence approaches, while 
the mononuclear lymphocytes and 
eosinophiles increase. With the es- 
tablishment of convalescence blood 
conditions return to the normal. 

Relapses. — A relapse is a grad- 
ually ascending temperature-curve 
extending over a week or longer 
after the temperature has been 
normal for a time (Fig. 49). A 
relapse was noted in 7 of 46 cases 
of my last series. In all, it was 
mild and no serious results followed. 
On the other hand, a prolonged low 
febrile curve causes great emacia- 
tion in children. Undue impor- 
tance has been attached to the con- 
dition of the spleen in these cases. 
The percentage of relapses varies 
with the nature of the prevailing 
epidemic. Blackader records 15 re- 
lapses in 100 cases, and Henoch 44 
in 375 cases. Apparently relapses 
occur independently of the mode of 
treatment and diet. 

Complications and Sequelae. — Skin. 
— Subcutaneous abscesses may oc- 
cur, and onchyia is common. TCry- 



the number of red blood- 
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328 TEE SPECIFIC INFECTIOUS DISEASES. 

sipelas and parotitis are uncommon. (Edema may be confined to the 
scrotum, or during defervescence the whole surface of the body may 
be oedematous. In a case of scrotal oedema coming under my observa- 
tion there were no casts or albumin in the urine ; the leucocytes were 
diminished. Henoch attributes oedema to cardiac weakness rather 
than to nephritis. 

Diphtheria. — Diphtheria is a very serious complication. I have 
observed it in 2 cases. 

The Lungs. — Bronchitis is a frequent complication. In the later 
stages of the disease in younger children it is likely to develop into 
bronchopneumonia, especially in cases in which the course of the dis- 
ease has been protracted. Pneumonia may occur in older children 
at the outset or in course of the disease. Gangrene of the lung is 
mentioned by Henoch as a rare complication. 

Arthritis. — Arthritis is uncommon. Usually only one joint is 
affected. It occurs in the post-typhoidal period and runs a favorable 
course. 

Nervous Sy stein. — Among the nervous symptoms which compli- 
cate or follow typhoid fever are aphasia, amblyopia, ataxia of the 
lower extremities, paralyses of various sets of muscles, double ptosis, 
and hemiplegia. In hysterical children there may be a post-typhoidal 
melancholia. In others stupidity may persist for a time. Recovery 
usually takes place in all forms of paralysis, aphasia, and melan- 
cholia. The paralyses are possibly due to a neuritis of toxic origin, 
as is the case with the other infectious diseases or an encephalitis. 
Hemiplegia occurs only as a result of embolism (Henoch). I have 
seen cases of ataxia and marked melancholia. The children made an 
excellent recovery. In one case, a boy of four years, catalepsy was 
present for a period of five weeks after the temperature had become 
normal. 

Meningitis occurred in an infant of 13 months. 

Kidneys. — Xephritis of a mild type may occur and persist long 
into convalescence. 

Pyuria occasionally occurs but is usually of no severity and 
requires no treatment. 

Perforation of the Intestine in Typhoid Fever. — The frequency of 
perforation of the intestine in children affected with typhoid fever, 
according to all available statistics, is 1.2 per cent, of all the cases. 
Of my own material of 222 cases there were 6 of perforation, in 5 
of which the diagnosis was confirmed by operation (2.7 per cent.). 
In the adult subject the frequency is 1 to 2.5 per cent, of all cases. 
Therefore, in the severer forms of typhoid fever in children, perfora- 
tion of the intestine is almost as frequent as in the adult. 

Time. — Most cases of perforation occur in the third week, some 



TYPHOID FEVEB. 329 

in the second week and least frequent are those in the first week of 
the "disease. One of my cases occurred in the sixth week. 

Symptoms. — Perforation may occur with a slow, insidious onset, 
or an acutely abrupt one. If there is active delirium of the low mut- 
tering type, it is impossible to fix the time of onset and the diagnosis 
becomes apparent only when peritonitis has made headway. In one 
of my cases in which the onset was insidious, the pain was com- 
plained of only six hours before the operation and yet it was found 
that peritonitis was then far advanced. In this case the day before 
the operation, the patient was somnolent, pale, and complained of 
anorexia. Vomiting appeared, followed by a drop in the tempera- 
ture, then pain and abdominal rigidity fully twelve hours after the 
onset, as subsequent history proved. In a case of brusque onset, the 
symptoms appeared in the forty-third day of the disease. The tem- 
perature had been normal since the fourth week of the disease. Pain 
localized around the umbilicus was the first abrupt symptom ; with 
this there was abdominal tenderness, and distension with disappear- 
ance of the liver dulness. The temperature rose to 104°, the pulse 
from 104 to 128. In another case with abrupt onset, vomiting fol- 
lowed by pain and abdominal tenderness was the first symptom. 
Thus the symptoms and mode of onset make each case a matter of 
individual study. 

Pain may be preceded by a chill or vomiting. It may be slight, 
sharp or intense, or paroxysmal and may not reach its greatest inten- 
sity for 24 hours after the perforation. Delirious patients do not 
complain of pain. Abdominal tenderness, even to slight palpation, 
accompanies the pain, as does rigidity. Even slight rigidity is diag- 
nostic. Distention is present in most cases, though in some there 
may be retraction. 

If there is fluid in the peritoneal cavity this will be demonstrated 
by movable dulness in the flanks and indicates advanced peritonitis 
or peritoneal reaction. 

Disappearance of liver dulness with accompanying abdominal 
distention demonstrates the escape of intestinal gases into the free 
abdominal cavity. 

A sharp fall in the temperature followed by an equally sharp rise 
is very significant when present with other symptoms, for a fall of 
the temperature alone is not diagnostic. 

In addition to the symptoms just noted as marking the onset ot' 
perforation in typhoid fever, there is an increase in the number of 
leucocytes. This was true of all my cases. In one case the leuco- 
cytes mounted from 6000 to 7000 to \0,000 to the c.mm., and in 
another to 13,000 to the c.mm. With all o( the above symptoms the 
respirations became rapid and shallow, due to the peritonitis. The 



330 TEE SPECIFIC INFECTIOUS DISEASES. 

prostration is evident even to collapse. The patients lie prone and 
resent interference. 

Diagnosis. — The diagnosis of perforation of the intestine in 
typhoid fever must therefore rest on the advent in a patient, otherwise 
doing well, of pain preceded by chill, vomiting or prostration, abdom- 
inal distention and tenderness with a drop in the temperature fol- 
lowed by a subsequent rise. A rise in the pulse and respirations, dis- 
appearance of liver dulness with subsequent appearance of fluid in 
the peritoneal cavity, leucocytosis and prostration. 

I have seen several cases in children who were operated on with 
the mistaken idea that there was a primary appendicitis. In these 
there was a typhoidal ulceration of the appendix without perforation. 
The pain which was referred to the appendix misled the physician. 

Prognosis. — The prognosis in intestinal perforation complicating 
typhoid fever in children varies with the time which has elapsed 
from the onset of the perforation to the treatment. Fitz has shown 
that if left alone 5 per cent, of the cases in adults recover. In chil- 
dren we have no corresponding statistics, except that of my 6 cases 1 
recovered. This was an undoubted case of perforation in which the 
inflammation localized itself to the right iliac fossa. Elsberg has 
included my cases in statistics of 25 cases of typhoidal perforation in 
children with operative interference, in which the percentage of 
recovery was 64 per cent., as compared with 22.4 per cent, in the 
adult. The prognosis, therefore, in children, in mixed statistics, is 
apparently more favorable than in the adult. 

Duration of the Disease. — The duration of typhoid fever varies 
within wide limits. Henoch, in his tabulation of more than 200 
cases, shows that the longest duration was seventy days ; the shortest 
seven to nine days. In my own cases the duration varied widely, if 
the rises in temperature were taken into account. The average dura- 
tion was four weeks and three days. The shortest case lasted ten 
days, and the longest lasted eleven weeks. 

Diagnosis. — Enough has been said to show that the diagnosis of 
typhoid fever in infancy and childhood is at times very difficult. 
With young children enteritis, pneumonia, meningitis, and even 
appendicitis may simulate typhoid fever in their onset. Cases which 
begin as a pneumonia are especially difficult of diagnosis. The cere- 
bral forms of typhoid fever may closely resemble meningitis. The 
history is very important. The onset of typhoid fever is gradual, 
the cerebral symptoms increasing in intensity as the disease progresses. 
An enlarged spleen and a few roseolar papules will be of service in 
making a diagnosis, but, on the other hand, an enlarged spleen is 
common to many conditions of infancy and childhood. In the most 
puzzling cases, such as those simulating enteritis of non-typhoidal 
nature, the roseola may at the outset be absent. 



TYPHOID FEVER. 331 

In a doubtful case the Widal agglutination blood-test should be 
made daily to clear up the diagnosis. In many cases this reaction 
is the only clue to the condition. During the prevalence of an epi- 
demic every case of pneumonia or doubtful meningitis or enteritis 
should be subjected to this test. 

Widal Agglutination Reaction. — The Widal agglutination reac- 
tion is of greater utility in making a positive diagnosis of typhoid 
fever in children than in adults. The fact that an enlarged spleen 
may be due to various causes, such as rickets, the occurrence of fevers 
of a remittent or continued type, possibly due to otitis, enteritis, pneu- 
monia, and the prevalence of diarrhoea of all kinds in infants and 
children, tend to make the Widal test of inestimable value. 

In a paper based on 84 of my cases of typhoid fever in infants 
and children, Gershel found the reaction positive in 81. Three hun- 
dred and twenty-nine examinations in all were made. Thirteen per 
cent, of the tests were positive at the end of the seventh day, 63 per 
cent, on the fifteenth day, and 89 per cent, on the twenty-fifth day 
of the disease. The reaction was negative in only 3 cases which 
gave the clinical symptoms of typhoid fever. These figures corre- 
spond to those obtained by Blackader in a smaller number of cases. 
A negative reaction unless the examinations have been repeated over 
a length of time is of no significance as excluding typhoid fever, 
whereas a positive reaction is absolutely pathognomonic of the dis- 
ease. In a few cases the reaction was not obtained until the close of 
the disease, when the temperature had been normal for some days. 
In another case of a child of three years, the reaction was not obtained 
until a relapse had occurred. 

Blood-cultures. — If in a given case a blood-culture can be made, 
a positive culture of typhoid bacilli may be established, even before 
the Widal reaction is obtained. Blood-cultures are available in cases 
of negative Widal reactions. 

The Ehrlich Diazo Reaction in the Urine. — Thirty-three cases 
were examined with reference to this reaction. The fifth day was the 
earliest day on which it was obtained. In the majority of cases the 
reaction was present from the seventh to the tenth day of the disease. 
The latest appearance was on the forty-seventh day from the outset 
of the disease. The reaction was absent in 15 per cent, of the eases. 
In all of the cases in which the Ehrlich reaction was obtained the 
Widal test was positive, and appeared in the first two weeks of the 
disease. The diazo reaction may appear before the Widal reaction, 
but in some cases the contrary is true. In conclusion, it may be said 
that in the presence of symptoms and signs of typhoid fever the diazo 
reaction is an aid to diagnosis, although not pathognomonic of the 
disease. 



332 THE SPECIFIC INFECTIOUS DISEASES. 

Of the clinical signs pointing to typhoid fever, the character of 
fever aids us but little. In the third week it may become intermit- 
tent, thus simulating malarial fever. In other cases the fever may 
be sustained with daily remissions until the fifth week. Typhoid 
fever with great ileocecal tenderness and pain may closely simulate 
appendicitis. A continued fever of longer duration than a week, a 
tremulous tongue, facie s, a pulse below 120, an enlarged spleen, and 
a few roseolar spots, will aid in the diagnosis. 

The diagnosis of typhoid fever must, therefore, be confirmed by 
the Widal reaction, except in a small percentage of cases. The pres- 
ence of roseola, enlarged spleen, facies, tremulous tongue, diarrhoea, 
and continued remittent fever are the clinical symptoms which should 
lead the physician to apply the test. 

Prognosis. — The prognosis of typhoid fever in infancy and child- 
hood is, as a rule, good. The mortality varies with the severity of 
the infection and the character of the epidemic. If the infection is 
severe, the complications will militate against recovery. Henoch, in 
375 cases had a mortality of 14 per cent. ; Blackader, in 100 cases 
lost only 1 ; Crozer Griffith had a mortality of 3 per cent. 

It is commonly supposed, and some authors lay stress on the fact, 
that the mortality of typhoid fever in children is lower than in the 
adult, and therefore the prognosis is better. This simple statement 
does not give us any idea as to the true mortality of typhoid fever in 
children. Some authors place the mortality in this disease as low 
as 4 or 5 per cent. This may be true of some statistics in certain 
epidemics. In a series of 222 hospital cases of my own of typhoid 
fever in children, ranging from thirteen months to thirteen years, the 
average mortality was 7.6 per cent. This would about express the 
average mortality of typhoid fever in children when epidemics of 
varying severity are taken into account. 

In this same material the mortality in one year was only 4 per 
cent., and in another as high as 16 per cent. It will be seen from 
this that hospital cases, from which all statistics are drawn, show that 
the mortality of typhoid fever in infants and children is much the 
same as in the adult cases. 

In 222 cases of typhoid fever there were 12 per cent, of relapses. 
In this we include only those cases in which there was a true relapse 
— that is, an average normal temperature for at least eight days pre- 
ceding the relapse. The average duration of the relapse was eleven 
days. The mortality in cases where there had been a relapse was nil. 

Treatment. — The treatment of mild cases of typhoid fever is purely 
symptomatic. There is little need for the administration of medi- 
cines. On the other hand, the severer cases are difficult to manage. 
This is especially true in the treatment of children, to whom it is not 



TYPHOID FEVEB. 333 

always possible to apply methods adopted with the adult. In cases 
in which delirium is present night and day bromides in large doses 
are efficacious. With older children they may prove useless, and 
morphine may then be necessary to meet the exigencies of the case. 

In the vast majority of cases milk, milk soups, and cereal soups 
form the basis of the diet. If there is progressive emaciation, one, 
two, or three raw eggs should be added to the milk daily. In other 
cases malted milk, junket, whey, or matzoon may vary the diet. It 
is well in protracted cases not to wait too long for a complete drop of 
temperature before resorting to other foods than milk. This is espe- 
cially true of cases extending over a period of seven or eight weeks, 
in which there is always a rise of temperature of half a degree or a 
degree above the normal for a few days, with a drop again to the 
normal or subnormal. In these cases there is a form of inanition 
fever, post-typhoidal in nature. Solid food should not be withheld 
too long lest the emaciation become extreme. After the fifth week 
we may in most cases allow the patient gruels containing cereals. 
After the temperature has fallen to the normal and remained there 
for four or five days, it is safe to return gradually to a full diet. It 
is doubtful if relapses occur as a result of too early feeding if this 
method is followed. In comatose states resort may be had to forced 
feeding. 

Alcohol. — Alcohol is not needed in mild cases. It is given in 
cases in which the pulse is weak and the temperature high. Delirium 
is no contraindication to its use, as it is in other affections. 

Heart. — The heart is stimulated by digitalis, strychnine, or cam- 
phor. If the heart has shown slight dilatation with a murmur devel- 
oping in the course of the disease, the patient should not be allowed 
out of bed too soon for fear that unfavorable symptoms may result. 

Hydrotherapy. — The temperature is controlled by hydrotherapy. 
The patient is placed in a bath at 100° F. (37.7° C), and the tem- 
perature of the water gradually reduced to 85° F. (29.4° C). With 
older children the temperature may be lowered still further. Chil- 
dren do not bear the classical Brand bath treatment well. The 
plunge bath is given three or four times daily whenever the tempera- 
ture is 103° F. (39.4° C.) or more. Should the child struggle very 
much against the administration of the bath, it is wiser to forego ir 
and substitute sponging. If the sponging is not followed by good 
reaction, the use of water should bo abandoned. In cases of delirium 
a bath once or twice daily at 105° F. (40.5° C.) has a quieting effect. 
The utmost gentleness must be observed while the patient is in the 
bath lest some latent abdominal complication may be aggravated. 

Hemorrhages,- Hemorrhages from the bowel are net frequent in 
children. They may occur early or late in the disease. In the latter 



334 THE SPECIFIC INFECTIOUS DISEASES. 

case they must be differentiated from hemorrhage due to enterocolitis 
of a post-typhoidal character. In hemorrhage due to typhoidal ulcer 
an ice-bag is applied to the abdomen, and small doses of opium, pref- 
erably the deodorized tincture, are administered to control peristalsis. 
Ergot and digitalis are given internally in order to contract the blood- 
vessels if possible. Enemata should not be given. If the hemor- 
rhage becomes excessive, it is proper to give hot saline enemata, and 
to infuse normal saline solution under the skin or into the veins. 

Enteritis. — Enteritis of an ulcerative or pseudomembranous char- 
acter occurring as a complication of typhoid fever is treated in the 
same manner as the primary affection of the same nature. 

Perforation. — Perforation should be treated on surgical princi- 
ples. As with adults, those perforations which occur late in the dis- 
ease, when the patient is in an exhausted and emaciated condition, 
give a less favorable prognosis than those which occur early. The 
surgical treatment will be more successful the sooner the diagnosis is 
established, for in those cases in which peritonitis has advanced to a 
marked degree the prognosis is fatal. The success of surgical treat- 
ment will also depend largely on the fact as to whether the perfora- 
tion is single or multiple. In one of my cases it was demonstrated 
at operation that no less than three ulcers had perforated, and there 
were as many more on the point of perforation, so that in this case 
simple sewing up of the ulcerated parts could scarcely have suc- 
ceeded in saving the patient, for in this very case a perforation after 
operation caused the death of the patient. In such cases the treat- 
ment of multiple perforations is a problem for the surgeon. In cases 
of doubt an exploratory operation for the presence or absence of a 
perforation is justifiable and even called for. 

Constipation. — In most cases of typhoid fever an enema will 
remove accumulated faeces from the lower bowel. Enemata are not 
given unless indicated. If the bowel contents are streaked with 
blood, enemata should be discontinued. In cases in which there is 
a slight rise of temperature during convalescence without apparent 
cause, grains v (0.3) hydrarg. cum creta should be given. Tympa- 
nites is treated as in the adult subject. The evacuations should be 
mixed with an equal volume of a solution of carbolic acid (1:20) 
as soon as passed. The hands of the nurse should be thoroughly 
cleansed after each movement. The patient's hands are cleansed 
daily, in order to avoid auto-infection. 

MALARIAL FEVER. 

(Paludism; Malaria; Intermittent Fever.) 

Malarial fever is an acute infectious disease due to the inocula- 
tion of the individual with the Plasmodium malarise. It is common 






MALARIAL FEVEE. 66b 

in infants and young children, and is believed to occur in utero. 
Crandall has reported a case in which symptoms developed eighteen 
hours after birth, and in which the plasmodium was found in the 
blood of the infant. Those who, like Moncorvo of Brazil, have oppor- 
tunities to observe malarial fever in young infants and children, find 
the greatest frequency under two years. The author has not met 
paludism as frequently in the nursing infant as in older children. 
The reason for this must lie in the fact that young infants are more 
protected from infection with veils, etc., than older children. One 
attack does not confer immunity to subsequent attacks ; on the con- 
trary, infants and children once the subject of paludal poisoning seem 
particularly liable to reinfection and relapses. 

The period of incubation varies from a few hours to weeks. In 
the tertian type it is believed to be from seven to fourteen days. In 
one of my cases the first chill appeared eleven days after the patient 
had left the malarious district. 

Etiology. — The essential cause of malarial fever is the same in 
infants and children as in the adult. It is an inoculation fever, and 
is conveyed to the human subject by a certain species of mosquito 
(Anopheles). The poison exists in the neighborhood of swamps and 
stagnant waters. 

The Parasite. — The plasmodium or protozoa of malaria circulates 
in the blood of infants and children, undergoing its cycle and sporu- 
lation in the same manner as in the adult. In one series of cases 
in infants and children that I studied, the tertian was the most preva- 
lent form of parasite. These cases occurred in New York City and 
its vicinity. This has been the experience of other New York City 
observers. One may assume that the blood will, as a rule, contain 
the parasite prevalent in a given locality. Several forms of parasites 
may exist in the blood of the same child, or there may be several 
generations of the same plasmodium. These may mature at different 
times, giving various types of fever in the same subject. In a tertian 
case, the fever may thus become quotidian, a second set of parasites 
causing a distinct chill and fever (paroxysm) on the day when the 
first generation is quiescent. We may have, as Mannaberg and 
others pointed out, simple and double tertians and quartans. But no 
combination of quartan parasites can simulate the simple tertian type. 
I have seen very few cases of quartan in children. They are uncom- 
mon in New York City, but I have seen preparations of the quartan 
type which were found in the blood of children in the Southern States. 
As in adults, tertian paroxysms may occur every day, caused by two 
sets of parasites which mature at about the same time daily, or one 
set matures at a different hour than the set of the following day. In 
such a, ease paroxysms would occur at the same hour only every other 



336 THE SPECIFIC INFECTIOUS DISEASES. 

day. Many children have a distinct severe paroxysm only every 
other clay, but on the intervening day a careful examination will 
detect a very low fever. This is probably due to a set of parasites 
which mature without producing marked chill or fever (abortive). 

The Blood. — In recent tertian I have found young spores in 
abundance in the blood a few hours after the chill. In some speci- 
mens the spores were free. Between paroxysms in tertian cases the 
blood contains colorless oval plasmodia — the fully developed body — 
leucocytes having rods and pigment-granules and rarely, small round 
forms with flagellar (Koplik). In stained specimens (methyl-blue) 
young native forms are found in all stages up to fully developed 
protozoa. The red blood-cell containing the parasite is distinctly 
enlarged. I have found in the stained specimen as in the unstained 
ones, the sporula in free groups, bodies with flagellar, and erythro- 
cytes with stained granules. The half-moons are also found in 
chronic cases. The blood contains free granules, and peculiar shrunken, 
brassy-colored, red blood-cells. Monti found the specific gravity of 
the blood to be increased. 

Morbid Anatomy. — Post-mortem examinations in cases of malarial 
fever in infants and children are exceedingly rare. Opportunity may 
be afforded when death occurs as the result of accident or of some 
other disease. Monti states that in fatal cases the spleen is enlarged ; 
the capsule is tense, and in places shows rupture. The pulp is dark 
red owing to pigment deposit (melanin). Old spleens show a dis- 
appearance of melanin and a deposit of yellow ochre pigment along 
the trabecular. In chronic cases the connective tissue is increased, 
the liver is enlarged, and there is atrophy of the liver-cells. The 
parasites are found in the blood. The endothelium of the blood- 
vessels contains yellow and brown pigment. In exceptional cases 
there are melanin deposits. In acute cases the bone-marrow is the 
seat of melanin deposit ; later this disappears, and the marrow is 
found to be yellow and fatty. The brain cortex in severe cases shows 
pigment deposit; sometimes there are thromboses and hemorrhages. 

Symptoms. — Children living in malarious districts do not always 
manifest malarial poisoning by having paroxysms of chills and fever. 
The disease is masked under the form of a progressive anaemia, with 
accompanying enlargement of the spleen. These patients may de- 
velop symptoms in from a few days to a few weeks after leaving the 
malarious region. 

The onset of a paroxysm is usually marked by the appearance 
of chills. In young infants a distinct chill is not always present. 
They become cold and blue at a certain time each day. In older 
children the paroxysm is indicated by headache and a feeling of 
lassitude, which comes on at a certain time each day, or by a dis- 



MALARIAL FEVER. 337 

tinct chill. In exceptional cases eclampsia or vomiting may usher 
in a paroxysm. In other cases there is no eclampsia, but the hands 
become cold, there is a feeling of faintness, and the child complains 
of being ill. Meanwhile there is a rise of temperature, during which 
there are muscular tremors of the extremities and a peculiar upward 
rolling of the eyes, indicating an impending convulsive seizure. The 
chill may occur during sleep. In one case the mother noticed that 
the child (three years of age) became pale during sleep, the hands 
and extremities became cool, and the pulse rapid. The febrile move- 
ment following the chill may be very slight, scarcely half a degree 
above the normal. In such cases the chill is not marked or is scarcely 
noticeable. This occurs in double tertian, in which one paroxysm is 
abortive. In most cases the fever is very high at first — so high that 
it is characteristic. A temperature of 106.5° F. (41.3° C.) is not 
uncommon, and is well borne. As a rule, the fever has a distinctly 
intermittent type. The temperature may rise after the initial chill 
and remain high for days, and then fall to the normal. In the simple 
form the fever lasts from four to twelve hours, and is followed by a 
critical perspiration, during which the temperature rapidly falls to 
the normal. In some cases the children appear free from symptoms 
in the interval between the paroxysms. Others suffer from headaches 
and a feeling of lassitude, and in infants there are gastric and intes- 
tinal disturbances. In protracted cases a distinct anaemia develops, 
with progressive enlargement of the spleen. Neuralgia of the periph- 
eral nerves has been noted in older children. 

During a paroxysm Monti noted polyuria, which persisted until 
the following day. 

The spleen enlarges rapidly, and in a short time may be felt as 
low down as the umbilicus. I have found the spleen markedly 
enlarged; in one case the organ was not palpable below the ribs, 
although a slight enlargement could be detected on percussion. 

The liver may be enlarged in chronic cases. 

In subacute forms chills are not present, but there is an irregular 
febrile movement, with progressive anremia and splenic enlargement. 

Repeated Attacks or Relapses. — Children, as well as adults, may 
have repeated attacks of malarial fever. As a rule, however, these 
so-called independent attacks in children are relapses, due either to 
inefficient treatment or to the development of a new series of para- 
sites. Infants may have relapses. I have treated such cases until 
all anaemia and signs of active malarial poisoning had disappeared. 
and then administered arsenic for months, only to find a return of the 
svmptoms after an interval o\' months. 

Diagnosis.- -The diagnosis of malarial fever is based upon an 
examination of the blood, [f a child suffers from pronounced 



338 THE SPECIFIC INFECTIOUS DISEASES. 

ansemia, malaise, pains in the limbs, and enlarged spleen the blood 
should be carefully examined. Expert knowledge is always necessary 
for a definite diagnosis. It is surprising to note the large number of 
cases beginning with chills and presenting an intermittent fever 
curve and enlarged spleen, diagnosed as malarious, in which parasites 
cannot be detected in the blood. Many septic and inflammatory proc- 
esses in infants and children simulate malaria. Rachitis, syphilis, 
gastro-enteric catarrh, otitis, pneumonia, typhoid fever with relapses, 
have all been mistaken for malarial fever. The diagnosis rests on an 
examination of the blood in all cases in which chills and fever or any 
of the symptoms described coexist with enlargement of the spleen. 

Quinine should not be administered until the blood has been very 
carefully examined. In other words, malaria should be diagnosed 
or excluded before resorting to this remedy, which was formerly much 
in vogue as a diagnostic test. Its use before diagnosis can only result 
in uncertainty, since there are rises in temperature, not due to the 
paludism, which may be influenced by quinine. A very high tem- 
perature of an intermittent type, in connection with other physical 
signs, should cause the physician to consider the possibility of paludal 
poisoning. 

I have not seen cases of the pernicious type. They occur in the 
Southern States. 

Acker has published 2 cases of malarial fever in children, in 
which there were the initial cerebral symptoms of coma and con- 
vulsions. Coma in one case came on in paroxysms. In the interval 
the child was rational. The sestivo-autumnal parasite (pernicious) 
was found in the blood. 

Prognosis. — The prognosis of malarial fever in ]STew York City is 
very good. With proper treatment the patient should recover. I 
have never met a fatal case. They occur in districts in which the 
pernicious type of the disease is prevalent. 

Treatment. — If possible, the patient should be removed from the 
malarious district. The remedies employed in all cases are quinine 
and arsenic, or their derivatives. 

According to Grolgi, quinine should be given before the paroxysm, 
and also in the intervals. The action of the drug is exerted directly 
upon the plasmodium. At this time segmentation of the parasite 
takes place in the blood, and most of the young parasites are free in 
the plasma. They then respond most quickly to quinine. Large 
doses should be given to infants and children, in order that the infec- 
tion may be destroyed quickly and completely. The soluble bisul- 
phate and muriate are suitable preparations. To an infant under 
one year of age grains ij (0.1) are given in a dose, repeated three 
times a day, the last dose being given from three to five hours before 



INFLUENZA. 339 

a paroxysm. To children between two and five years of age grains 
iij to v (0.2 to 0.3) are given in the same manner. Some infant- 
take quinine readily when it is suspended in powder form in milk 
or water; others are given a piece of chocolate, and when the surface 
of the mouth is coated with the candy the drug is administered. 
Euquinine is a preparation tasteless and odorless, and is readily taken 
by children. It has the disadvantage of causing vomiting in some 
children. The dose is the same as that of quinine. The syrup of 
yerba santa is a good menstruum. In cases in which children cannot 
take quinine by mouth, Jacobi advises giving it per rectum, dissolv- 
ing the drug in a solution of tartaric acid. In the severe form of 
pernicious malarial fever of the tropics quinine is given by the hypo- 
dermic method. 

Infants and children with chronic or subacute forms of malaria 
are likely to be constipated. Under these conditions I have found 
calomel more efficient in clearing the gut than castor oil. 

After the quinine treatment has been continued for some time the 
spleen will be observed to diminish in size and the paroxysms to dis- 
appear. If the anaemia persists, it is well, after diminishing the 
frequency of the dosage of quinine, to combine it with small doses 
of Fowler's solution. The arsenic must occasionally be temporarily 
discontinued, or the functions of the stomach will become deranged. 
Warburg's tincture does not seem to be very efficacious with children 
under five years of age, nor with older children, unless given in very 
large doses. Children do not develop cinchonism as quickly as adults, 
and the quinine may therefore be continued for a long time. Treat- 
ment should not be suspended until the spleen is no longer palpable 
and the anaemia has disappeared. Quinine should then be continued 
in small doses at regular intervals. 

The preparations of cinchona, such as cinchonidia, cinehonidin, 
chinidin, etc., are not reliable. The following is Baccelli's formula 
for the subcutaneous use of quinine in pernicious intermittent fever : 

Quinin. muriat 15 grs. (1.0). 

Natrium chlorat 1 gr. (0.06). 

Aq. destillat 5iiss (10.0). 

INFLUENZA. 
(La Grippe; Acute Catarrhal Fever.) 

Influenza is a specific infectious disease chiefly affecting the 
mucous membranes. It is highly contagious, although all individuals 
exposed do not contract the disease. It occurs in the form ot pan- 
demics in which whole communities are affected. This pandemic 
form occurs less frequently in children than in adults, and is of 



340 TEE SPECIFIC INFECTIOUS DISEASES. 

interest to the physician only when an epidemic prevails. The 
endemic form of influenza affects children more frequently than 
adults, and is the form which will be described, although in its symp- 
toms it closely resembles the epidemic form. The endemic form may 
occur at any season of the year. In large cities influenza is endemic, 
and appears to be more prevalent after rapid changes from lower to 
higher temperatures. Rapid fluctuations in the humidity of the 
atmosphere in winter also favor the development of the germs of this 
disease. In ]\ T ew York City, midwinter and spring are the seasons 
when outbreaks of this affection occur. Influenza sometimes becomes 
epidemic in hospital services. I have recently had this experience 
and Holt has published a study of influenza pneumonia in institutions. 

Age. — Influenza may affect the newly born infant. A case of 
this kind is reported by Townsend in the Transactions of the Amer- 
ican Pediatric Society. The disease is most frequent between the 
ages of six months and five years. The younger the child, the more 
severe the affection. 

Mode of Infection. — Individuals are infected by coming into con- 
tact (contact infection) with others suffering with the disease. The 
germ is contained in the sputum and the nasal secretions ; therefore 
poorly ventilated rooms and public conveyances and institutional con- 
ditions favor the transmission of the disease. Parents may transmit 
it to their children in the act of kissing, and wet-nurses who have la 
grippe are likely to infect the infant at the breast. 

Etiology. — The epidemic form of influenza has been studied by 
Pfeiffer and Kitasato. Pfeiffer isolated a bacillus from the bronchial 
mucous membrane, trachea, and lungs. This bacillus, which is now 
believed to be the essential cause of epidemic influenza, is exceed- 
ingly small, and two or three times as long as it is broad. It has 
rounded extremities, occurs in pairs and chains, does not stain by 
Gram's method, and in influenza, pneumonia, and encephalitis is 
found in enormous numbers in the lungs. It is called the Bacillus 
influenza?. It is still an open question whether it occurs in the blood. 
Although this bacillus has been found in sporadic cases of endemic 
influenza, competent observers, Luzzato among the latest, have found 
that in a large number of endemic cases of influenza the Pfeiffer 
bacillus is absent. In its place is found the Frankel diplococcus. 
This is thought to be the essential cause of an important group of 
cases of endemic and sporadic influenza in children — the so-called 
pneumococcus grippe. Predisposing elements in the etiology of 
endemic influenza are exposure to cold and a diminution of the 
strength of the individual. One attack does not protect the indi- 
vidual from subsequent attacks. 

Incubation.— Influenza is believed to have an incubation period 



INFLUENZA. 341 

of from twelve hours to three days. Endemic influenza occurs fre- 
quently in large cities and at times local epidemics of the disease 
are seen. 

Morbid Anatomy. — Inasmuch as influenza is rarely fatal, the 
pathological anatomy is imperfectly formulated. In fatal cases a 
general inflammatory condition of the mucous membrane of the nasal 
passages and of the larynx and trachea, is found. The surface of 
the lining membrane of the bronchi is reddened, covered with muco- 
pus, and the membrane itself is infiltrated with small round cells. 
There may be a diffuse inflammation of the smaller bronchi, with 
peribronchitis and inflammatory reaction. Areas of bronchopneu- 
monia or lobar pneumonia are found in the lungs. The heart is 
dilated and the seat of myocarditis. There may be endocarditis and 
the kidneys may present an acute nephritis. The pleurae are inflamed, 
and there may be serous or serofibrinous pleurisy or empyema. 

Among the other lesions are those due to the complications, otitis, 
meningitis, inflammation of the gastro-intestinal tract, and cerebro- 
spinal meningitis. 

Symptoms. — It has been customary to divide the symptomatology 
of endemic influenza as it occurs in children into clinical forms. 
According to my experience, there is no sharp dividing-line between 
the various forms of endemic influenza as seen in children. The 
gastro-intestinal, nervous, and pneumonic forms are frequently pres- 
ent in the same patient. Endemic grippe as it occurs in children in 
New York City will be described, the epidemic or pandemic form 
being ignored. 

The most frequent form is the catarrhal of an acute and even 
subacute type. The infant or child may at the outset have a chill. 
Most frequently there is vomiting, and also fever, and pains in the 
head and limbs. There is a coryza, and in many cases a croupy, 
barking cough. The eyes are injected, the face is red and flushed. 
and the child presents an appearance resembling that of the first 
stage of measles. The mucous membrane of the throat is deeply 
injected and the tonsils inflamed and enlarged. 

The temperature is elevated; in fact, at the outset it is as high in 
this disease as in malarial fever, 106.5° F. (41.3° C). The cough 
is sometimes incessant. The irritation in the throat is extreme, and 
vomiting after the coughing paroxysm may lead the physician to 
believe that he is dealing with whooping-cough. In young- infants 
these symptoms may last for a day or two, during which the move- 
ments may become green and even diarrheal. This diarrhoea is 
sometimes so severe as to be a prominent feature o\' the disease. The 
prostration both in infants ami children is marked. After two or 
three days tin 1 catarrhal condition o( the upper air-passages subsides. 



342 



TEE SPECIFIC INFECTIOUS DISEASES. 



and the patient develops symptoms of an acute bronchitis of a severe 
type. These forms of grippal bronchitis have at the ontset a high 
febrile curve, and a fever persisting for days. The bronchitis affects 
the smallest bronchi. They may develop a bronchopneumonia in 
small areas. 

In other cases the bronchitis passes suddenly into a pneumonia 
without a preceding chill. The pneumonia of la grippe may be 
lobular or lobar in type. In the vast majority of cases the pneu- 
monia is of the pneumococcus variety. 
Especially severe are the cases of grippe 
which are ushered in with a chill, high 
fever and cerebral symptoms, such as 
sopor, delirium, and rigidity of the neck 
muscles. In many of these cases exami- 
nation of the chest reveals pneumonia. 
These cases are not so common among 
infants as among older children. 

Cases in which there is a cerebro- 
spinal infection in no way differ in symp- 
tomatology from cases of cerebrospinal 
meningitis due to the meningococcus or 
the pneumococcus. The endemic grip- 
pal forms of cerebrospinal meningitis 
may be caused by the influenza bacillus 
(Sanger). I have had six cases of cere- 
brospinal meningitis caused by the bacil- 
lus of influenza. The diagnosis was con- 
firmed by lumbar puncture and the culti- 
vation of the bacillus on media. The 
child at first complains of fatigue, and 
has a tendency to sleepiness, cries out and 
starts in its sleep, and suffers from intense headache. After a time 
vomiting with rigidity of the muscles of the neck sets in. These 
symptoms increase in intensity, sopor finally setting in with all the 
symptoms of a cerebrospinal meningitis. These cerebral cases are rare. 
A common form of grippal attack is that in which all the symp- 
toms of nasopharyngeal inflammation are present. There is also mild 
bronchitis of the larger tubes. The temperature may fall to the 
normal in the morning or toward noon, but toward evening it rises 
from one-half a degree to three degrees above the normal. The 
child plays in the afebrile intervals. It may awake from sleep in 
a peevish, irritable mood, or may start in its sleep. These symp- 
toms may continue for a week or longer. In many of these cases 
there is serous or purulent otitis media, or there may even be a 





Fig 


50. 








m 


E 


M 


E 


M 


E 


X ioi° 

X 

< 

u. 

UJ 

CC 

3 100 

I- 
< 

DC 

UJ 
Q. 

5 

UJ 

H 99° 

DAY OF 

DISEASE 

PULSE 

RESP. 
DATE 
















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4 


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106 


100^ 


106 


X^ 


X 


X 


Feb. 2 


3 


4 



Endemic influenza with bron- 
chitis in an infant seven months 
of age. 



INFLUENZA. 



343 



mastoid inflammation from the outset. In other cases the patient 
has an intermittent or remittent fever. The fever, if a continued 
one, has morning or evening remissions. Examination of the heart 
may reveal an acute endocarditis, although marked symptoms of car- 
diac involvement may be absent. 

Symptoms referable to the kidney have received little attention 
in text-books. In endemic grippe there is almost always a slight 















Fig. 


51 


















DAY 


M 


E 


M 


E 


M 


E 


M 


E 


M 


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. 104° 
103° 

H 
Id 
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k 102° 
< 

u. 

UJ 

DC 

< 101° 

UJ 

D. 

UJ 

h 

100° 

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DAY OF 

DISEASE 


1 


g 


3 


i 


5 


6 


7 


8 


PULSE 




y 




120 


126^ 


150 


136 

y 


J* 


RESP. 




X 


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X 


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X 


X 


30 


DATE 


Feb. 2 


3 


4 


5 


6 


i 


8 


9 



Endemic influenza, lobar pneumonia of the lower lobe of the right lung. Child 
two and one-half years of age. 



trace of albumin in the urine, which, as a rule, disappears at con- 
valescence. Occasionally, I here is a true nephritis, with easts, de- 
creased secretion, and blood. Such eases have been described by 
Freeman. Of grave import are the eases of nephritis in endemic 
grippe which at first shew a trace of albumin and a few h\ aline. 



344 THE SPECIFIC INFECTIOUS DISEASES. 

epithelial, and blood-casts, with a very small (microscopic) amount 
of blood in the urine. The urine is normal in amount. The con- 
dition is revealed only by the microscope. (Edema is absent. The 
child is at first pale, but this pallor disappears later. The trace of 
albumin in the urine, however, with a few casts and blood-cells, per- 
sists for months. These cases may be mistaken for " cyclic " albu- 
minuria. They are really nephritis of an insidious character follow- 
ing endemic grippe. 

I have seen cases of endemic grippe complicated with swelling 
of the parotid and submaxillary glands and of the lymph-nodes of 
the neck. 

Otitis media is a common complication of influenza in winter and 
spring. Such cases may run their course without complication or 
result in mastoiditis or sinus thrombosis. 

Duration. — The duration of endemic grippe is from two or three 
days to as many weeks. I have seen cases present a temperature- 
curve for three weeks, but have not met the cases of protracted dura- 
tion, with or without fever, described by Filatow, and would regard 
such cases as peculiar to the country of that author. 

Prognosis. — The prognosis of endemic grippe is favorable. If 
complications supervene, it varies with their nature. 

Diagnosis. — The diagnosis presents no difficulties. In some cases 
the nervous symptoms may cause the physician to suspect meningitis 
when pneumonia is present. A careful physical examination will 
dispel the doubt. Meningitis and pneumonia may be present in the 
same case. Otitis may supervene without the presence of marked 
symptoms referable to the ear. An aural examination should be 
made in all cases in which fever persists and physical examination of 
the lungs and other organs fails to reveal abnormal conditions. 

Treatment. — The treatment of influenza is simple. At the outset 
in the milder cases small doses of quinine are administered, to control 
the headache, restlessness, and fever. For the angina small doses of 
ferric chloride are given to infants every one to three hours. In 
older children, the throat is, in addition, sprayed two or three times 
daily with salt solution or a solution of boric acid. The fever is 
treated by sponging; packing or baths are rarely necessary. The 
bowels of infants are washed out with high enemata if diarrhoea 
sets in, and milk food is temporarily suspended. Pneumonia, if 
present, is treated as outlined in the section on that disease. Otitis 
should be treated by early incision of the drum-membrane, as even 
cases in which no pus, but only serum, is present are relieved by this 
procedure. With older children the use of phenacetin alone or in 
combination with monobromate of camphor is permissible if the head- 
ache and pains in the limbs are very troublesome. A grain of each 



GLANDULAR FEVER. 345 

may be given once or twice daily for a short time. The prostration 
is best combated by the use of strychnine alone or combined with 
caffeine. Alcohol is not well borne in these cases, since it is likely 
to cause gastro-intestinal symptoms. 

In those cases in which there are meningeal symptoms lumbar 
puncture should be performed to determine the presence of meningitis. 

GLANDULAR FEVER. 

(Pfeiffer.) 

Glandular fever is a form of infection which manifests itself by 
an enlargement of the lymph-nodes of the neck, with accompanying 
enlargement of the liver and spleen, and an initial period of fever. 
It occurs from the second to the eighth year of life, but may occur in 
infancy. During an extensive epidemic J. P. West observed it in 
the nursing infant. 

Etiology. — The etiology is obscure. This disease is a species of 
infection or toxaemia. In some cases (West) there has been diarrhoea, 
in others constipation, and in most cases a slight injection of the naso- 
pharynx. It is possible that the infectious agent gains access to the 
lymph-channels through the gut or nasopharynx. This would account 
for the involvement of the mesenteric glands, as observed by Pfeiffer, 
and for the infection of the nodes of the neck through the thoracic duct. 

Symptoms. — After slight malaise, or even without prodromata, 
children are attacked with fever, restlessness, headache, vomiting, and 
pains in the limbs. After a few hours of these premonitory symp- 
toms, swelling of the cervical glands on one or both sides is noticed. 
These glandular swellings extend from beneath the body of the jaw 
along and beneath the upper third of the sterno-mastoid muscle. The 
lymph-nodes beneath the muscle are also affected. After one or two 
days these glands or nodes not only increase in size, but nodes at the 
back of the neck and in the supraclavicular region are also affected. 
In the cases recorded by West the axillary and inguinal lymph-nodes 
were also involved. The temperature at first ranges from 102° to 
104° F. (38.8° to 40° C), but in from twenty-four to forty-eight 
hours it may fall by crisis. There is a slight redness of the pharynx 
or the color of the mucous membrane may be normal. There is pain 
on deglutition, and there may be a slight cough, but no distinct pul- 
monary affection. In both Pfeiffer's and West's cases the liver ami 
spleen were enlarged. In the cases of Starck, Rauchfuss, and Pro- 
tossow these enlargements were not always present. 

Lymph-nodes. — The lymph-nodes may enlarge to the size of a 
pigeon's egg. The redness of the pharynx is disproportionate to the 
enlargement of the nodes (Rauchfuss), so that it is hardly permissible 



346 THE SPECIFIC INFECTIOUS DISEASES. 

to speak of an anginal lymphadenitis, as in scarlet fever. In both 
Starck's and West's cases there was enlargement of the nodes, which 
were not painful, but sensitive to pressure. The swelling of the 
carotid lymph-nodes began, as a rule, after a few hours, was in most 
cases first visible on the left side of the neck, and reached its height 
from the second to the fourth day. The glands on the opposite side 
of the neck then became affected. The swelling rarely continues 
unilateral. It is uniform, as thick as an index-finger (West), and 
is composed of several nodes. There is a stiffness of the neck and 
also a sensation of choking. Suppuration is absent. There is in 
all cases a tenderness of the abdomen about the umbilicus, which, in 
Pfeiffer's opinion, indicates an infection of the mesenteric nodes. 
West found the mesenteric nodes enlarged in 37 cases. 

In New York there have occurred every year in the winter months 
a large number of cases in which the symptoms were limited to en- 
largement of the lymph-nodes on either side of the neck at the angle 
of the jaw. Sometimes the nodes in the axilla were also enlarged. 
There was a high febrile movement for days and weeks. These 
cases resolved, leaving no further evidences of infection. I have 
regarded such cases as those of glandular fever. 

Diagnosis. — The disease is readily differentiated from mumps. 
In some epidemics the submaxillary glands were involved, but never 
the parotid. The appearance of the swelling of the lymph-nodes first 
on one side, and then on the other side of the neck is characteristic, 
and should be differentiated from the glandular swellings occurring 
with grippal affections or pneumonia. Heubner has reported cases 
in which there was a complicating nephritis. 

Duration. — The fever disappears after a few hours or may last 
two or three days. It may recur later. The glandular swellings, 
however, increase or persist nine to twenty-seven days, the average 
duration being sixteen days (West, Rauchfuss). 

Treatment. — As the affection has a tendency to spontaneous recov- 
ery, the treatment is purely symptomatic. 

MENINGITIS. 

Classification of the Different Forms of Meningitis. — The simplest 
classification is that which divides meningitis into the primary and 
secondary forms. The primary form includes cerebrospinal menin- 
gitis of the epidemic type, or cerebrospinal fever, as also the sporadic 
forms of this disease, and, as a separate entity, the pneumococcus 
meningitis. In the secondary forms we have the tuberculous and 
pneumococcus meningitis, the latter being secondary to pneumonia, 
endocarditis, or injury of the cranial bones. Third, there are the 



MENINGITIS. 347 

pyogenic forms of meningitis, due to staphylococci, streptococci or 
secondary either to the disease of the cranium or local infections. 
Fourth, there are the forms of meningitis secondary to typhoid fever, 
influenza, colon bacillus, diphtheria, gonorrhoea, syphilis, anthrax, 
actinomycosis. Fifth, in a separate rubric there is the so-called 
serous meningitis, which is recognized as a secondary form of dis- 
ease, due probably to streptococci or pyogenic organisms. It will 
be seen that this classification recognizes both the sporadic and the 
epidemic forms of the cerebrospinal fever as the same disease due to 
the same essential cause, the meningococcus of Weichselbaum. 

Barlow and Gee divide simple meningitis in infants and children, 
as to locality, first, into the vertical form, which is a leptomeningitis, 
and affects the vertex of the cerebrum, sometimes spreading toward 
the base, and often involving the cord ; and in the second class they 
include the so-called postero-basic forms of meningitis, in which the 
exudate is confined principally to the posterior part of the base of 
the brain. 

All forms of meningitis may be cerebrospinal as to distribution 
and it should be understood that the term cerebrospinal meningitis 
has been retained and when used refers more particularly to the men- 
ingococcus form. 

In constructing this section the author has utilized 114 cases of 
meningitis occurring in his hospital service. They were divided into 
the following groups: 68 were cases of the cerebrospinal form of 
meningitis of the epidemic type. Of the remaining cases, 35 were 
tuberculous forms of meningitis, 1 case a so-called staphylococcus 
meningitis, 1 case a primary pneumococcus meningitis, 3 cases strep- 
tococcus meningitis, and in 6 cases a bacillus corresponding to the 
influenza bacillus in cultural characteristics. 

The author will first consider cerebrospinal meningitis of the epi- 
demic and sporadic type, and then will consider the so-called vertical 
meningitis and postero-basic meningitis of Barlow and Gee, serous 
meningitis, and finally tuberculous meningitis. 

Cerebrospinal Meningitis (Cerebrospinal Fever; Spotted Fever; 
Meningococcus meningitis; Petechial Fever; Malignant Purpuric 
Fever). — Cerebrospinal meningitis is an acute infectious disease, the 
characteristic lesion of which is an exudative inflammation of the pia 
mater of the brain and spinal cord. It occurs in epidemics, but may 
occur sporadically. 

Etiology. — Cerebrospinal meningitis, both in its epidemic and 
sporadic forms, is duo to an infection by the Diplococcus meningitidis 
intracellularis of Leichtenstern, Weichselbaum, and Jager. This 
micro-organism is a diplococcus reminding one strongly in its form 
of the gonococcus. It is decolorized by the Cram stain. It is found 



348 TEE SPECIFIC INFECTIOUS DISEASES. 

not only in the body of the pus-cell — hence its name — but in the 
exudate also outside of the pus-cell. 

Though the epidemic form of cerebrospinal meningitis is caused 
in the vast majority of cases by this micro-organism, there is another 
group of cases of the cerebrospinal type which is caused by the Diplo- 
coccus pneumonia?. This latter class of cases has been described by 
better, Foa, and Bordoni-UfTreduzzi. These cases may occur epi- 
demically also, but are generally seen in combination with lobar or 
bronchopneumonia, or as a complication of otitis media. The form 
of affection discussed in this section is rather the sporadic and epi- 
demic type of cerebrospinal meningitis caused by the intracellular 
diplococcus above mentioned. In the epidemics of this disease so far 
observed, it is not unusual for several members of a family to be 
attacked. The rule, however, is the contrary. The cases in an epi- 
demic number several hundreds, the last epidemic in New York 
amounting to somewhat over 1000 cases. 

The disease seems to have no marked tendency to spread. In 
large cities the epidemics occur in the spring of the year ; and, after 
the epidemic has run its course, sporadic cases are observed in the fall 
and winter months. 

Mode of Infection. — It has been a matter of great speculation as 
to how the infection is conveyed from person to person in this disease, 
if such does occur; and also as to the manner in which the micro- 
organism — the intracellular diplococcus — gains access to the circula- 
tion. Cases are observed here and there, and I have seen two such 
cases in the last epidemic, in which the disease is complicated by 
pneumonia, the meningitis and the pneumonia both being due to the 
intracellular diplococcus. These cases, however, are exceptional. It 
has been supposed that the micro-organism gains access to the circu- 
lation through lymph-spaces in the mucous membrane of the nose and 
conjunctiva?. 

I have published one case in which the Diplococcus intracellularis 
was found in the secretion of the conjunctiva in a child suffering 
with the disease, in whom the meningitis had been preceded by a con- 
junctivitis. Wright has published a case in which the intracellular 
diplococcus was found in the nasal secretions of a person suffering 
from influenza symptoms, mild headache, fever, and constitutional 
disturbances, which might very well have been a mild form of cere- 
brospinal meningitis. A micrococcus, so-called Micrococcus catarrh- 
alis, is found in the normal secretions of the nose, and it has been 
mistaken time and again for the Diplococcus intracellularis. 

It has been intimated that the infection may gain access to the 
circulation through the respiratory organs. However these facts may 
be, they do not definitely establish how the infectious material gains 



PLATE XVI 




Cover-glass Stain of the Sedimented Fluid Obtained by Lumbar 
Puncture in Epidemic Cerebrospinal Meningitis. 

Polymorphonuclear cytology; vacuolization of the leukocytes and lympho- 
cytes; peculiar conformation of the nuclei in cells; large cells resembling lym- 
phocytes; Diploeoeeus meningitidis in the cell body of the leukocyte* and 
outside of the cell bodies in smaller numb 



PLATE XVII 



M 








% 



•S% 






» 



£< 






V 



£g 



^ 



Section of the Spinal Cord, showing the Exudate on the Surface, 
More Marked Posteriorly and Involving the Anterior and Posterior 
Nerve Roots. Epidemic cerebrospinal meningitis in an adult; 
death on the fifth day of the disease. 



PLATE XVII I 

mm *b 

^ ^ % « 9 



The Exudate of the Early Stage and Inflammatory Reaction 

in the Pia Mater. 

This shows: Swelling cells of the pia; fibrin in the exudate; the leuke 
invasion; new connective-tissue cells; nuclear division ; large cells containing 
three or more leukocytes described by Counei Iman, Mallorj and Wright. 



MENINGITIS. 349 

access to the circulation, or whether the disease is conveyed from 
person to person. 

Occurrence. — Cerebrospinal meningitis is distinctly a disease of 
young people. Eotch reports a case in an infant six days old. The 
youngest case of the epidemic type seen by me occurred in an infant 
ten weeks old. Of 111 cases reported by Councilman, 29 occurred 
in infants and children. Of a series of 70 cases of cerebrospinal 
meningitis reported by me, 47 per cent, were under two years of 
age; the youngest was four months of age, and 61 per cent, of the 
cases were under four years of age. The oldest child in my hos- 
pital service was fourteen years of age. Thus the average age was 
two years. 

Morbid Anatomy. — In certain sporadic cases of cerebrospinal 
meningitis of the epidemic type the clinical symptoms may have been 
very marked, and yet post-mortem examination fails to reveal any 
gross macroscopical lesions of the brain and pia mater. They appear 
to be normal. Under the microscope, however, a slight infiltration 
of the pia with pus and fibrin and a new growth of cells is seen. In 
other cases there is an extensive infiltration of the pia with serum, 
fibrin, and pus. The exudation is especially profuse at the base of 
the brain and on the posterior surface of the cord, more especially in 
those cases which will hereafter be described as postero-basic menin- 
gitis. The ventricles of the brain may be markedly distended with 
serum and even pus. Among the associated lesions found are sub- 
serous punctate hemorrhages of the endocardium; ecchymoses and 
petechias of the skin, hyaline and granular degeneration of muscle, 
multiple abscesses of the skin, suppuration of the joints, parenchy- 
matous degeneration of the heart, liver, and kidneys, and swelling 
of the lymph-nodes and spleen. In all the epidemic cases of the type 
referred to in this section the Diplococcus intracellularis is found in 
the exudate of the pia mater and cortex of the brain and in the fluid 
of the ventricles. 

Symptoms. — There are certain types of cerebrospinal meningitis 
which are seen both in the epidemic and sporadic forms of the disease. 
The malignant types are seen rather in the epidemic forms; whereas 
the milder types are seen in the sporadic cases. Clinically, therefore, 
we may divide all cases of epidemic cerebrospinal meningitis into 
three forms: The first form is the malignant type of the disease, in 
which the children, in previous good health, are attacked and die 
within twenty-four or thirty-six hours of the onset of the disease. 

The following ease, one of the first of the epidemic of 1901, is a 
characteristic example of this type: An infant twelve months old. 
nursed at the breast; perfectly formed, large, healthy, bright child, 
never previously affected by any illness, nursing, and bowels normal. 



MENINGITIS. 349 

access to the circulation, or whether the disease is conveyed from 
person to person. 

Occurrence.- — Cerebrospinal meningitis is distinctly a disease of 
young people. Kotch reports a case in an infant six days old. The 
youngest case of the epidemic type seen by me occurred in an infant 
ten weeks old. Of 111 cases reported by Councilman, 29 occurred 
in infants and children. Of a series of 70 cases of cerebrospinal 
meningitis reported by me, 47 per cent, were under two years of 
age; the youngest was four months of age, and 61 per cent, of the 
cases were under four years of age. The oldest child in my hos- 
pital service was fourteen years of age. Thus the average age was 
two years. 

Morbid Anatomy. — In certain sporadic cases of cerebrospinal 
meningitis of the epidemic type the clinical symptoms may have been 
very marked, and yet post-mortem examination fails to reveal any 
gross macroscopical lesions of the brain and pi a mater. They appear 
to be normal. Under the microscope, however, a slight infiltration 
of the pia with pus and fibrin and a new growth of cells is seen. In 
other cases there is an extensive infiltration of the pia with serum, 
fibrin, and pus. The exudation is especially profuse at the base of 
the brain and on the posterior surface of the cord, more especially in 
those cases which will hereafter be described as postero-basic menin- 
gitis. The ventricles of the brain may be markedly distended with 
serum and even pus. Among the associated lesions found are sub- 
serous punctate hemorrhages of the endocardium; ecchymoses and 
petechia of the skin, hyaline and granular degeneration of muscle, 
multiple abscesses of the skin, suppuration of the joints, parenchy- 
matous degeneration of the heart, liver, and kidneys, and swelling 
of the lymph-nodes and spleen. In all the epidemic cases of the type 
referred to in this section the Diplococcus intracellularis is found in 
the exudate of the pia mater and cortex of the brain and in the fluid 
of the ventricles. 

Symptoms. — There are certain types of cerebrospinal meningitis 
which are seen both in the epidemic and sporadic forms of the disease. 
The malignant types are seen rather in the epidemic forms; whereas 
the milder types are seen in the sporadic cases. Clinically, therefore. 
we may divide all cases of epidemic cerebrospinal meningitis into 
three forms: The first form is the malignant type of the disease, in 
which the children, in previous good health, are attacked and die 
within twenty-four or thirty-six hours of the onset of the disease. 

The following case, one of the first of the epidemic of 1904, is a 
characteristic example of this type: An infant twelve months old, 
nursed at the breast; perfectly formed, large, healthy, bright child, 
never previously affected by any illness, nursing, and bowels normal. 



350 THE SPECIFIC INFECTIOUS DISEASES. 

On the morning of the onset of the illness the child appeared drowsy 
and stupid, refused the breast, vomited once, but was not feverish. 
In the evening the infant was still drowsy and listless ; the tempera- 
ture rose to 103° F. ; pulse 110 and weak. There was no peculiarity 
about the eyes, no stiffness of the muscles of the neck or body. Early 
on the morning of the next day the child awoke with a cry, and the 
mother discovered red spots on the cheeks; the face was slightly 
swollen; the eyes had a staring expression, and the child was appar- 
ently blind. A few hours later the entire face, hands, and body were 
covered with blotches of an ecchymotic character. The tissues of 
the extremities seemed to be hard to the touch and swollen. The 
buttocks and body appeared as if the child had been beaten. Petechia? 
and ecchymosis involved the whole surface of the body. At this time 
the temperature was 101° F., pulse very weak, scarcely perceptible 
at the wrist, the lips blue, the reflexes abolished. There was no 
rigidity of the muscles of the neck. There was no Kernig symptom. 
The pupils were uneven and did not react ; there was a slight con- 
junctivitis. The breathing was weak and catchy. Death super- 
vened within a few hours. These cases are not unusual in epidemics, 
and here and there sporadic cases occur of this type. 

Another type of case is the more common form of the disease. 
A child in apparent health will suddenly complain of headache, fever, 
and begin to vomit. There may be a chill. The fever is generally 
high, the pulse rapid. The headache is very severe and is a constant 
leading symptom. There is also intense pain at the back of the neck, 
extending down the back. The child is irritable and restless, tossing 
about, intolerant of light and sound. Any interference and touch on 
examination of the surface of the body causes pain ; in other words, 
there is hyperesthesia. After a few hours rigidity of the muscles 
at the back of the neck appears, and this rigidity may increase to 
opisthotonos ; in some cases on the second day there may be repeated 
convulsions. When the disease is completely inaugurated the child 
lies in bed in a characteristic attitude, the lower extremities flexed, 
the arms flexed, the head slightly retracted. The children, for the 
most part, lie on the side. 

TYith the full onset of symptoms in some epidemics petechia? 
appear with ecchymoses over the whole surface. These petechia? 
vary in size from a pin-head to large blotches resembling hemorrhages 
due to traumatism. Ecchymoses are seen especially on the extensor 
surfaces of the lower extremities. The patients complain of constant 
headache, some are very restless, delirium sets in; the delirium may 
be of a mild or muttering type. In some cases there is no sleep, the 
patients toss here and there in the bed, and complain of constant 
pain in the head. The bowels may be constipated; in some cases 



PLATE XIX 




Convexity of the Brain. Epidemic cerebrospinal meningitis with 
death on the fifth day of the disease. Purulent exudate. 



FIG 2 




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MENINGITIS. 351 

there is diarrhoea. The urine may contain evidences of a nephritis. 
In other cases no such evidence is present. The amount of urine 
passed in some cases may be enormous; in other words, there is 
polyuria. The spleen may he enlarged. The type of case just de- 
scribed corresponds to the mass of cases seen in an epidemic. 

A third type of this disease is more puzzling in its character ; it 
affects infants and young children in apparent health. Infants and 
children are noticed to have a constant rise of temperature ; there 
may be vomiting; there is restlessness; if nursing, they refuse the 
breast. The fever after a few days takes an intermittent course, 
mounting as high as 104° and 105° F. at certain times of the day; 
falling to the normal or subnormal at others. In the intervals of 
freedom from temperature the children or infants will play, and 
when the temperature rises they complain of headache (if old enough), 
become drowsy and irritable, refuse nourishment, and develop symp- 
toms which point toward meningeal inflammation, such as the Kernig 
symptom, rigidity of the back of the neck. In these cases the typical 
symptoms of meningitis are not always present. Delirium may not 
be constant or may not extend over the twenty-four hours. The 
rigidity of the neck may not be very marked, especially in young 
infants. The Kernig symptom in children, especially below two 
years of age, may not be evident. The most characteristic feature 
of these cases, it seems, is the prolonged temperature of an intermit- 
tent type, closely resembling malarial fever. In fact, many of these 
cases have been mistaken for malaria. 

There is a fourth type of case, which will be described under the 
heading of Postero-basic Meningitis, which is observed not only spo- 
radically, as has been remarked by Still, but also in epidemics. 

Mode of Onset. — In all the cases that I have had an opportunity 
to observe in my hospital and private practice, and in which the diag- 
nosis was confirmed by lumbar puncture, the main characteristic of 
the disease was its sudden onset. In only a small percentage of cases 
was there a doubtful history of sudden onset. In this respect the 
disease differs markedly from other forms of meningitis, especially 
those of the tuberculous type, in which the invasion is slow and 
insidious. From a study of the symptoms the onset may simulate 
an attack of gastro-enteritis in some children. 

Cerebral Symptoms. — If the fontanelle is not closed there is dis- 
tinct bulging or tenseness, even in the early stages of the disease. 
certainly before the fifth day. The patients suffer from delirium ol- 
eoma, and in the milder cases headache is the principal symptom, 
and periods of consciousness alternate with those of stupor. Rigidity 
of the neck, either slight or marked, is present at one time or another 
in all cases, and opisthotonos is present in about 70 per cent, of the 
cases (Plate XX.). 



352 TEE SPECIFIC INFECTIOUS DISEASES. 

According to Osier, neck rigidity or opisthotonos was not present 
in the adult form of primary pneumococcus meningitis. In one case, 
however, of my own, of primary pneumococcus meningitis in a child, 
neck rigidity was present. There is hyperesthesia of the surface, 
and the patients cry out if the bed is jarred or the skin touched. 
In some cases there are recurrent rigors and convulsions, either uni- 
lateral or general. There may be facial paralysis and hemiplegia 
in the early or the later stages of the disease. 

Be flexes. — In the majority of cases of epidemic cerebrospinal 
meningitis the patellar reflex is present in the early stages of the 
disease, but it may disappear in the rapidly fatal or moribund cases. 
The so-called tache cerebrale of Trousseau is obtained in all cases. 

Babinski Beflex. — Babinski, a French neurologist, described the 
extension of the great toe and separation of the other toes on irrita- 
tion of the plantar surface of the foot as a characteristic sign of dis- 
ease of the pyramidal tracts or the lateral columns of the cord. In 
epidemics of cerebrospinal meningitis this phenomenon is obtained in 
only a small percentage of cases, in contradistinction to what is noted 
in the tuberculous form of meningitis, in which it is common, being 
obtained in 6 of 26 of my cases of tuberculous meningitis. The 
Babinski reflex is of very little value in children and infants below 
two years of age, for a phenomenon closely resembling it is obtained 
in perfectly normal individuals at this age (Fig. 83). 

Kernig Symptom. — The Kernig symptom — that is, an inability 
to extend the leg on the thigh when the latter is flexed on the trunk — 
is obtained at one time or another in all cases of cerebrospinal menin- 
gitis. In children below two years of age, however, this sign must 
be accepted with caution because of the natural tendency in infants 
and children of this age to contraction of the lower extremities, a 
variety of normal myotonia (Fig. 52). On the other hand, in cases 
of so-called cerebral symptoms complicating pneumonia and typhoid 
fever, the Kernig phenomenon may also be apparent, so that, although 
it is present in all cases of meningitis, it is not pathognomonic of the 
disease. It may be absent in cases of the malignant type in which 
there are collapse symptoms. 

Hyperesthesia. — In the majority of cases of cerebrospinal menin- 
gitis, after the symptoms are fully established, the patients are irri- 
table, refuse to be comforted, start at the slightest sound, lie mostly 
on the side, the arms and lower extremities flexed, the body taking 
a crouching position. Any attempt to disturb the patients is met 
with resistance. The amount of hyperesthesia varies not only in 
the different epidemics, but in different types of the disease, but it is 
present in most cases, thus being in marked contrast to what is seen 
in the tuberculous form of meningitis, in which the children lie in a 



MENINGITIS. 



:;53 



stuporous condition, do not notice their surroundings, cannot be 
roused, and are not as irritable as in the epidemic cerebrospinal form. 

MacEwen s Sign. — MacEwen has shown that in children, in 
various forms of meningitis, percussion of the skull over the anterior 
horn of the ventricles will give a tympanitic note if the head is so held 
that the frontal or parietal bone may be percussed over the anterior 
horn of the ventricle. The patient is placed in the sitting posture, 
with the head inclined to one side, and percussion of the inferior 
frontal or parietal bone is carried out. 

The MacEwen sign is obtained in those cases of the cerebrospinal 
meningitis in which there is an accumulation of fluid in the ventri- 
cles, and was absent in only 2 cases of 13 studied with a view to 



Fig. 52. 





r - # t* 



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Kernig symptom in a case of cerebrospinal meningitis of the epidemic type. 

nine years of age. 



Female, 



obtaining this sign. It is more common in the tuberculous forms 
of meningitis. 

Facial Paresis. — In epidemic cerebrospinal meningitis facial pa- 
ralysis may occur in the very severe cases at the outset of the disease, 
especially if the base of the brain is involved. 

Paralysis. — There may be paralysis not only of the facial mus- 
cles, but of the extremities on one or the other side, either at the outset 
of the disease or toward the close. 

Eyes. — There may be an initial conjunctivitis, keratitis, strabis- 
mus, contraction, dilatation, or inequality of the pupils: neuritis of 

23 



354 TEE SPECIFIC INFECTIOUS DISEASES. 

varying grades of the disk; atrophy, and finally purulent choroiditis. 
There is no appreciable impairment of vision in some cases. In a 
four-months-old baby paralysis of the orbital muscles of one side 
appeared early in the disease. A peculiar phenomenon has been 
observed by me and described by others referable to the pupils: If 
an attempt is made to bend the head forward as the patient lies in 
bed unconscious, the pupils will be observed to dilate (mydriasis). 

Contrary to the generally accepted opinion, we have found that 
expert examination of the fundus of the eye in cases of cerebrospinal 
meningitis of the epidemic type revealed few changes in the optic 
pupilla in the majority of cases. In some cases there was dilatation 
of the veins, or congestion without neuritis. In only one case was 
there descending neuritis. This corresponds very closely to what 
Barlow and Gee found to be true both of the vertical and postero- 
basic forms of meningitis. In a group of 26 cases of meningitis of 
the tuberculous variety, however, examined by an expert ophthalmol- 
ogist, some change was found in the fundus in fully 77 per cent, of 
the cases. This change consisted either of an optic neuritis or papil- 
litis, or the presence of tubercles in the choroid. 

Blood, — The leucocyte count in cases of cerebrospinal meningitis 
of the epidemic type ranges from 20,000 to 55,000 to the cubic milli- 
metre in 55 per cent, of the cases. There are cases, however, with a 
low leucocyte count of 11.000 to 12,000 to the cubic millimetre. 
This corresponds very closely to what was found by Osier to be true 
of the adult cases. In tuberculous forms of meningitis, however, of 
infants and children, in 40 per cent, of the cases there is a leucocyte 
count of 20,000 to 25,000 to the cubic millimetre, and in 60 per cent, 
of the cases the leucocyte count is below 20,000 to the cubic milli- 
metre. Rarely, however, does the leucocyte count exceed 24.000. 

In the fatal cases, in which the lumbar puncture may yield a fluid 
markedly purulent, the leucocyte count may mount from 35,000 to 
55,000 to the cubic millimetre. On the other hand, a fatal case with 
fluid obtained by lumbar puncture might show a leucocyte count not 
exceeding 23,200. 

Cases which have recovered may show in the course of the disease 
a leucocyte count of 14,000 to 28,000 to the cubic millimetre, and 
they may have mounted as high as 45,000. It cannot, therefore, be 
said that a prognosis as to recovery or fatal issue can be made from 
the leucocyte count alone in cerebrospinal meningitis. 

Pulse. — The pulse in cerebrospinal meningitis, as a rule, is rapid 
and irregular ; but there are periods in which the pulse is slow, some- 
times 80 or even lower. This is not as common, however, as the 
rapid pulse. 

Respirations. — The respirations, as a rule, are shallow, increased 



MENINGITIS. >>•>■> 

in frequency, and irregular in rhythm. In a few cases there may 
be Cheyne-Stokes respiration. In other cases Cheyne-Stokes respira- 
tion is not seen in the whole course of the disease ; as the fatal issue 
approaches, the respirations may cease before the heart ceases to beat. 
In the terminal stages the respirations sometimes fall to 10 a minute, 
and the pulse to 50, indicating the onset of general paralysis. 

Temperature. — There is no curve of temperature which is dis- 
tinctive of cerebrospinal meningitis. It may be said, however, that 
the temperature in many cases is of the intermittent variety, and for 
this reason these cases are frequently mistaken for malaria. In the 
intermittent type of temperature the remissions are very great, some- 
times ranging eight degrees in twenty-four hours ; that is, a tempera- 
ture which has been high will in a few hours fall to the subnormal to 
rise again. This is not uncommon and may extend over weeks. On 

Fig. 53. 




Cerebrospinal meningitis. Female infant, eight months of age ; unconscious on admis- 
sion to hospital; fatal issue. (Meningococcus.) 



the other hand, the temperature may remain persistently high, espe- 
cially in the rapidly fatal cases of the malignant type. 

In the chronic cases the temperature may fall to and continue 
within normal limits for days or even weeks. In some eases, after 
the temperature has remained normal for days or weeks, there may 
be a so-called recrudescence of temperature of an intermittent typo 
extending over a week or more. This does not preclude ultimate 
recovery. In one case in the recent epidemic the temperature con- 
tinued of the intermittent type, with the remissions mentioned above, 
for eight weeks, fell to the norma] for a week, rose again, continued 
intermittent for a week, and finally fell to the normal and remained 
there. In this respect the temperature may even resemble typhoidal 
curves of the third or fourth week. 



356 



THE SPECIFIC INFECTIOUS DISEASES. 



Spleen. — The spleen may be enlarged in some cases. 

Ear. — The ear may be the seat of otitis or mastoiditis. Deafness, 
especially where the base is involved, may supervene very early. 

Anterior Fontanelle. — The anterior fontanelle in infants and 
children in whom the structure has not closed, may be tense or dis- 
tinctly bulging; and in those cases in which there is considerable 
accumulation of fluid the posterior fontanelle may reopen. 

Skin. — In many of my cases there has not been that prevalence 
of skin rash described by most authors. It has been only in the 
last epidemic of 1904 in which skin eruptions were prevalent. They 
included the roseola resembling that of typhoid fever. The roseola 
appears, as a rule, at the outset of the disease, and may recur in the 





































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Cerebrospinal meningitis. Female child, eight years of age; temperature at two 
extremes of the illness. Recovery- (Meningococcus.) 

course of the disease. Purpuric spots extending over the general sur- 
face are common at the outset, as well as ecchymoses, and these may 
disappear within a few days, leaving absolutely no trace of their 
presence; or recurrent crops of ecchymoses and petechise may appear 
in the course of the disease. Herpes labialis varies in different 
epidemics as to its frequency, being absent in the majority of cases 
in some epidemics, and being frequent in others. Herpetic eruptions 
may occur elsewhere on the trunk or extremities. I have seen exten- 
sive herpes on the hand. One case has come to my notice in which 
the herpes were quite generally distributed over the trunk and 
extremities. 

Complications. — In some epidemics of cerebrospinal meningitis 
there are few complications. Those cases which recover do so with 
very little to show that the nervous system in any of its extent has 
been severely compromised. The eyesight is not injured, nor is there 
subsequent hydrocephalus in any cases. In other words, the recov- 



MENINGITIS. Sty I 

eries when they occur are complete and satisfactory. This is espe- 
cially true of small epidemic outbreaks occurring over the course of 
years. In the recent epidemic of 1904, however, the complications 
were more frequent; joint complications were observed in 2 cases of 
a series of 30; blindness was not an uncommon complication, as also 
deafness. Recovery was incomplete, with hydrocephalus irj several 
cases of a series of 30. Pneumonia was observed as a complication 
of cerebrospinal meningitis of the epidemic type in 2 fatal cases. 

Sequelae. — Recovery may take place without compromise of any 
of the senses or functions of the patient. Both in young and older 
children hydrocephalus, either of a mild or severe type, may super- 
vene in the course of the disease ; it may run a short course and the 
patient recover with a mild form of hydrocephalus, which in years 
gives rise to nervous symptoms, such as partial paresis or epileptic 
form of convulsions. Severe types of hydrocephalus lead in many 
cases to permanent idiocy or imbecility, with or without paralysis. 
In some cases blindness or deafness results as a direct cause of menin- 
gitis. Arthritis, which sometimes complicates the disease, has a ten- 
dency to get well and leave no marks of its presence. Many patients 
recover with so-called sensitive spines, or paresis of certain sets of 
muscles, which later in life becomes apparent. 

Optic neuritis or blindness occurring in the course of the disease 
very frequently retrogrades, and the patients, on recovery, bear no 
marks of any ocular lesion. 

Characteristics of the Fluid Obtained by Lumbar Puncture- — The 
fluid obtained by lumbar puncture in cases of meningitis, studied 
both as to cytology and bacteriology, is of particular interest as 
regards the possibility of making a diagnosis. The cytology of the 
fluid obtained in cerebrospinal meningitis shows a preponderance of 
the polynuclear leucocytes. In a small percentage of cases the mono- 
nuclear cells, contrary to the general belief, may be prevailing ele- 
ments, thus closely resembling what is seen in tuberculous meningitis. 
In chronic cases mononuclear leucocytes abound; and in these cases, 
especially those of the basic type described by Still, the cytological 
picture resembles that of tuberculous meningitis. The fluid obtained 
by lumbar puncture in cerebrospinal meningitis may be quite clear, 
with scarcely any sediment, and may be markedly purulent, in this 
respect differing from the fluid obtained in tuberculous forms of 
meningitis, which is clear in at least TO per cent, of the cases. 

Bacteria. — In the vast majority of cases of cerebrospinal menin- 
gitis the Diplococcus meningitidis intracellularis of Weichselbaum 
was found at one time or another, either in leucocytes or outside of 
the leucocytes. In the chronic cases, however, there are rimes in 
which the Diplococcus intracellularis is not found. This is especially 



358 THE SPECIFIC INFECTIOUS DISEASES. 

true of the posterior basic cases. In those cases in which the diplo- 
coccus has not been found during life in the fluid obtained by lumbar 
puncture, it may be discovered postmortem in the fluid obtained from 
the ventricles of the brain. I have recently punctured the brain ven- 
tricles of infants during life in cerebrospinal meningitis. The char- 
acteristics of the fluid are identical with those of the fluid obtained 
by lumbar puncture in the same cases. 

Course of the Disease. — The course of the disease after the symp- 
toms are fully developed in typical cases has been indicated in the 
first part of this article. The patient lies unconscious, the head is 
retracted, and in some cases the back arched. The delirium is con- 
stant, and the patients complain of headache. The neck is rigid; 
some patients complain also of pain in the course of the sciatic nerves. 
When disturbed they cry out with pain. There may be rigors, 
during which the patients become cyanosed and the heart feeble. 
The respirations are shallow and irregular. If the case lasts over 
a week the patients may refuse nourishment, and on this account 
marked emaciation sets in. 

In some cases the disease takes on an abortive type. After a 
period of headache, fever, vomiting, intervals of remission of all 
symptoms, including temperature, alternate with intervals in which 
the temperature runs an intermittent course, with a return of the 
headache, stupor, and uneasiness, convalescence finally sets in, and 
the patients rapidly recover. 

Other cases result fatally in a few days. Some cases run a course 
of from eight to fifteen weeks, with the temperatures described, great 
emaciation, and finally make an incomplete recovery. Others attain 
a freedom from symptoms, but emaciation and paralysis persist, or 
even blindness and deafness, until an intercurrent affection ends the 
sufferings of the patient. As will be shown, there are few recoveries 
in children below two years of age. In other cases recovery takes 
place, but idiocy, hydrocephalus, blindness, or palsy may persist. 

Diagnosis. — Cerebrospinal meningitis must be differentiated from 
tuberculous meningitis, typhoid fever, and pneumonia with cerebral 
symptoms. 

It is distinguished from tuberculous meningitis by the sudden 
onset, its continued or intermittent higher febrile movement, the 
early onset and marked rigidity of the neck and opisthotonos, and, 
as has been intimated, the higher leucocytosis, and finally by the 
examination of the fluid obtained by lumbar puncture. Cerebro- 
spinal meningitis is distinguished from typhoid fever by the fact that 
in the latter disease there is a leucopenia and a constant enlargement 
of the spleen with Widal reaction. On the other hand, there may 
be cases of typhoid fever in which the cerebral symptoms are very 



MENINGITIS. 359 

marked and in which a meningitis may be present, due to an inva- 
sion of the meninges of the brain and cord by the typhoid bacillus. 
In this set of cases the diagnosis will be very difficult without the aid 
of a lumbar puncture. This latter procedure should be made in order 
to exclude the severer affection of cerebrospinal meningitis. A pneu- 
monia with cerebral symptoms will at the outset closely resemble a 
cerebrospinal meningitis, especially in very young children. Even 
if an examination of the lungs reveals a pneumonia during an epi- 
demic of meningitis, we cannot always exclude the latter disease 
without resort to a lumbar puncture, for cases of meningitis of the 
epidemic cerebrospinal type caused by the intracellular diplococcus 
are met in which pneumonia is present as a complication. On the 
other hand, pneumonia per se with cerebral symptoms does not, as a 
rule, give us the very marked rigidity, opisthotonos, petechia?, intense 
cephalalgia, and Kernig symptom seen in cerebrospinal meningitis. 
I have, however, met isolated cases, both of pneumonia and typhoid 
fever with cerebral symptoms, in which a Kernig symptom was 
obtained, as well as the so-called tache cerebrale of Trousseau, 
although these cases are certainly exceptional; in any doubtful case 
we should not hesitate, as has been said, to resort to lumbar puncture 
in order to clear up a given case. 

Prognosis. — The mortality of cerebrospinal meningitis varies 
largely with the severity of the infection and in different epidemics. 
In some epidemics the malignant cases seem to predominate ; that 
is, those cases which die within a short time (from twenty-four hours 
to five days) after the onset of the disease. On the other hand, in 
small epilemics the mortality may not exceed 48 per cent. There 
are epidemics in which the mortality has risen as high as 90 per cent. 
Especially fatal are the postero-basic cases and those attended by 
malignant features at the very outset of the disease. The prognosis, 
unfortunately, cannot be predicted in cerebrospinal meningitis, either 
from the nature of the fluid obtained by lumbar puncture, or from 
the condition of the blood as reflected in the leucocyte count, or the 
range of the temperature. We can only say that it is especially fatal 
the younger the patients. We have records, however, of cases of 
cerebrospinal meningitis occurring in infants of five months and one 
year of age, substantiated by culture and lumbar puncture, in which 
recovery occurred. 

The prognosis has recently been much improved by the serum 
treatment of Flexner. In 400 cases collected by Flexner and Jobling 
treated by their serum, the mortality was lowest in cases treated in 
the first three days of the disease (11 to 13 per cent.), in cases from 
the second to the twentieth year; on the seventh day ot' the disease 
the mortality of injected cases ranged from 24 to 26 per cent. Below 



360 TEE SPECIFIC INFECTIOUS DISEASES. 

2 years of age the mortality, when treated from the fourth to the 
seventh day, was 16 to 25 per cent., and 50 to 66 per cent, when 
treated later. 

Treatment. — Serum. — One of the greatest advances of modern 
medicine is, as with diphtheria, the serum treatment of cerebrospinal 
meningitis of the meningococcus type. Among the various sera which 
have been perfected and proposed, the Flexner serum is now by selec- 
tion the one utilized. Its action is bacteriolytic and therefore the 
great advantage in its use is the proposal by Flexner to inject this 
serum into the spinal canal and thus reach the bacteria directly. 

It has been found that after one or more injections the number 
of bacteria (meningococci) is greatly reduced and the fluid withdrawn 
from the cerebrospinal canal contains either very few bacteria or none 
at all. It thus acts in a manner differently from the diphtheria 
serum which is injected subcutaneously and affects the disease through 
a contained antitoxin. It is well to remember that the Flexner serum 
is of virtue only in cases of the meningococcus variety. 

The serum should be used as soon as the symptoms of meningitis 
are apparent. A tentative lumbar puncture should be made as early 
as possible. Before lumbar puncture it is not always possible to 
diagnose the exact form of meningitis present. Therefore to avoid 
delay which may be harmful a so-called exploratory puncture is made 
at the start. If the fluid thus obtained is turbid an immediate injec- 
tion of serum is made and the cerebrospinal fluid examined. If men- 
ingococci are found the injection of serum is repeated until the 
symptoms indicate that the disease is under control and convalescence 
established. 

Before proceeding to puncture, every piece of apparatus necessary 
should be in readiness. The needle is carefully boiled, the tubing 
to be attached to the needle is sterilized, as also the funnel by which 
the serum is introduced into the canal. The serum having been care- 
fully warmed to the temperature of the body, the site of puncture is 
cleansed, the needle introduced, and the fluid of the subarachnoid 
space allowed to flow out. After withdrawal of 30 to 40 or more c.c. 
of fluid, 30 c.c. of the serum is allowed to flow slowly into the canal 
just evacuated. The syringe has long been discarded by me for the 
Quincke funnel. After all the serum has flowed into the canal the 
needle is withdrawn and the puncture sealed with a sterile gauze 
dressing. Flexner and Dunn advise the repetition for three succes- 
sive days of 30 c.c. of serum. In young infants this should be done 
on account of the dangerous nature of the disease. 

In older children it is well to study the symptoms closely and to 
repeat the injections on successive days as needed. In some cases I 
have found that two injections sufficed to bring about convalescence. 



MENINGITIS. 361 

I have carried out the intracranial injection of serum in infants 
in whom the effect of the lumbar punctures was not apparent after 
the first few injections of serum and in whom basic symptoms were 
in evidence. Cushing and Knox first carried out these intracranial 
injections of serum in posterior basic cases. My experience with this 
method as yet is too limited to make any positive statements. 

In these cases the puncture-needle is entered with the infant in 
the recumbent posture, in the parietofrontal angle of the anterior 
fontanelle to one side of the median line. The inferior angle is 
chosen. The fluid comes through the canula quite readily and the 
serum is introduced in the same manner as in lumbar puncture. 
Aseptic precautions as to shaving of the head and site of the cranial 
puncture are very important, as the least oversight may lead to a 
meningoencephalitis due to a mixed infection. 

Lumbar Puncture. — The symptoms calling for lumbar puncture 
are increased exudate in the subarachnoid space, with extreme rigid- 
ity, opisthotonos, coma, delirium, bulging fontanelle ; in young in- 
fants chills with subsequent rises of temperature are indications for 
a repetition of and introduction of serum by lumbar puncture. In 
those cases in which coma and delirium supervene at the very outset 
of the disease, lumbar puncture may be performed within twenty-four 
hours of the onset of symptoms. We should not hesitate after the 
first puncture to repeat the procedure within twenty-four hours, as 
indicated above, if symptoms either recur or remain stationary. In 
young infants and children especially repeated lumbar puncture 
seems to be called for by the very fact that in these subjects the con- 
tinued pressure and increase of fluid in the subarachnoid space and 
in the ventricles of the brain increases the tendency to dilatation of 
the ventricles, a serious complication which may lead to collapse 
symptoms, sudden death, or ultimate chronic hydrocephalus. In 
those cases in which at the outset of the disease the head retraction is 
very marked, the lumbar puncture is sometimes unsatisfactory, inas- 
much as little fluid is withdrawn. In these cases the exudate at the 
base of the brain and the extreme retraction of the head may cut off 
the communication of the subarachnoid space and spinal cord with 
the ventricles of the brain. The canal of Majendie, through which 
this communication is sustained, is in these cases occluded. These 
are the cases in which ventricular puncture is suggested. 

Lumbar puncture alone is not curative. It relieves symptoms of 
headache and delirium. It removes a certain amount of purulent 
exudate which is a menace to the vital structures of the brain and 
cord, and is thus a method of drainage rather than a curative meas- 
ure. It may, in cases of sudden distention of the ventricles of the 
brain with fluid, avert death. 



362 THE SPECIFIC INFECTIOUS DISEASES. 

The amount of fluid withdrawn at each puncture should be from 
30 to 50 c.c., depending greatly on the extent of pressure present, as 
indicated by the manner in which the fluid flows from the puncture 
cannula. If the fluid flows drop by drop, a small amount, 20 to 30 
c.c, is withdrawn. In some cases the fluid fairly spurts from the 
cannula, and in such cases 50 c.c. or more may be withdrawn. In 
other cases the exudate is so thick and purulent that it will not flow 
from the cannula except in large, thick drops at long intervals. We 
should not in these cases attach a syringe to the cannula and apply 
suction to the fluid, for in this way, it has been shown, hemorrhages 
may be caused in the spinal cord and the pia of the brain. Anaes- 
thesia is not needed in young children but may be administered to 
older, boisterous children. As might be supposed, a number of modi- 
fications on the procedure of simple lumbar puncture have been 
proposed. 

General Treatment. — Aside from the serum treatment of cerebro- 
spinal meningitis the general conduct of the case is of utmost im- 
portance. 

Diet. — The maintenance of the nutrition of the patient is a most 
important element in these cases of meningitis. In those cases in 
which the patient is comatose and refuses to take nourishment by the 
mouth, it is a difficult problem to maintain the nutrition of the 
patient. In many cases nourishment must be given by the rectum, 
and in some must be introduced into the stomach by means of gavage. 
In the first case we frequently find that after nourishing the patient 
by the rectum for a few days this viscus becomes intolerant and very 
little nourishment is retained. Peptonized milk and somatose in the 
form of enemata are the most available forms of nourishment by the 
rectum. Gavage does not meet our ideals as to nourishment of the 
patient, because there is resistance to this procedure on the part of 
the unfortunate sufferers. Thus, each individual case will be a 
problem to the physician ; some patients take food with avidity, and 
in these cases milk and broths are the principal forms of nourish- 
ment given. 

Drugs and Hydrotherapy. — The bowels of these patients are gen- 
erally constipated, and from time to time a cathartic must be given ; 
the most preferable cathartics are the mercurials, calomel in dose of 
\ to 2 grains, are given to clear the bowels. This may be repeated 
at intervals of forty-eight to seventy-two hours. Enemata do not 
seem to reach the majority of cases. The headache is very severe in 
a great number of cases, and no remedy that we know of completely 
relieves the symptom. Morphine given in moderate doses relieves 
some patients. In others this drug is not well borne, and the patients 
seem to become more stupid and the circulation weaker under its 



MENINGITIS. 363 

continued use. The author has tried the various drugs of the coal- 
tar series. 

Pyramidon in doses of 5 to 7 grains, given at intervals of three 
to four hours, seems to have relieved a certain percentage of cases. 
The head is shaved and the ice-cap applied. Even this procedure is 
not well borne by some patients, and they strongly protest against it. 
It seems to increase the pain. 

The delirium is treated with liberal doses of mixed bromides of 
sodium, potassium, and ammonia. In some cases chloral in moderate 
dose is added to this mixture, and is well borne by the patient. It 
does not depress the circulation. 

The irregularity of the heart which is present in a large number 
of cases does not call for any active treatment. Alcoholic stimulants 
should be avoided if possible, as there seems to be no indication for 
their use. One of the principal modes of meeting restlessness, the 
occasional high temperature, the rigors and accompanying cardiac 
weakness, is the systematic use of warm baths. The patients are 
placed in a warm bath of a temperature of 105° to 107° F. three 
times in the twenty-four hours. Care should be taken to lift the 
patient gently from the bed into the bath. Massage should not be 
performed as in the ordinary bath given in pneumonia, while the 
patient is in the bath, inasmuch as this friction irritates and excites 
the patient and seems to cause a great deal of pain. The duration 
of the bath should be from five to ten minutes. The time for giving 
it should be chosen when the temperature is on the rise, the irrita- 
bility of the patient at this time being greatest. If the heart should 
become very weak, camphor is indicated ; if possible, by the stomach. 
If this is not feasible, camphor, in the form of camphorated oil, should 
be given subcutaneously. 

Acute Lepto-meningitis (Vertical Meningitis). — In this form of 
meningitis the vertex or superior surface of the brain is affected : the 
region of the cerebrospinal foramen may escape, but not necessarily 
so, and in some cases the base also may be affected. 

Occurrence.- — It is found in the newborn and children as a com- 
plication of sepsis, erysipelas, pneumonia, influenza, diseases of the 
ethmoid and mastoid bones, perforation of the bones of the skull, or 
suppurations elsewhere, such as retropharyngeal abscess. 

Etiology. — The essential cause is an invasion of the tissues of the 
meninges of the brain by streptococci, pneumococci, the influenza 
and coli bacilli. 

These cases are sometimes difficult of diagnosis, because in many 
of them the classical symptoms of meningitis arc absent. In the 
early stages of the disease anatomically th< re is dryness and opacity 
of the pia hypersemia. Later, cedematous conditions of the pia 



364 TEE SPECIFIC INFECTIOUS DISEASES. 

supervene with the formation of lymph and fibrin along the sulci 
and in the tissue of the pia mater and on its surface. Later, the puru- 
lent exudate may extend over the surface of the brain, involving not 
only the base of the brain, but also the spinal cord. In some cases 
the exudate does not penetrate the ventricles of the brain; in others 
inflammation extends into the ventricles. In this form of meningitis 
there are complications either primary or secondary, such as pneu- 
monia, empyema, pericarditis. 

Symptoms. — : The diagnosis is difficult. The symptoms are often 
latent. Eetraction of the head is very often absent, and ocular symp- 
toms are rarer ; in fact, the fundus in many cases is found to be 
normal. Vomiting is less frequent than in the basic forms of menin- 
gitis to be described, or in the cerebrospinal forms just described. 
Convulsions of a violent character may be present; they may be 
repeated throughout the disease, and are associated in some cases with 
high temperature ; in other cases they are absent. These convulsions 
may be epileptiform. Clonic spasms may be local at first, but, as a 
rule, they become bilateral and general. There may be, as in menin- 
gitis, tonic spasms. The duration of the disease is shorter than in 
posterior basic meningitis, may last from one to two days to as many 
weeks, and in exceptional cases may become chronic. In many cases 
it is impossible, unless a lumbar puncture is made, to differentiate 
these cases from tubercular meningitis. !N"or is it possible, if the 
exudate extends to the spinal cord and rigidity sets in, to differentiate 
a so-called vertical case from an ordinary cerebrospinal meningitis of 
the epidemic type unless a lumbar puncture is made. The differen- 
tiation, therefore, of these cases must depend on a continued observa- 
tion of the case and the performance of lumbar puncture. 

Posterior Basic Meningitis. — Posterior basic meningitis is so 
called because the inflammation affects the posterior part of the base 
of the brain and the structures in this location, and rarely spreads to 
the vertex of the brain, at most only affecting the tips of the temporo- 
sphenoidal lobes, and in some cases extending forward to the optic 
commissure. These cases were first described by Gee and Barlow, 
in the Bartholomew Hospital Reports of 1878, and subsequently by 
Still in 1898. 

Occurrence. — The affection occurs in infants and children below 
the age of two years, and is rarely seen in older children. I have seen 
exceptional cases in children of three and five years of age. 

Etiology. — These cases, according to Still, and confirmed by my 
own observations, are caused by a diplococcus which is identical with 
the diplococcus of Weichselbaum, Jager, and Leichtenstern, an intra- 
cellular diplococcus not staining with Gram's method. Although 
Still thought that these were only sporadic cases of the epidemic form 



PLATE XXI 



/ 



/ 



i j\ 



H 




Posterior Basic Meningitis. (Gee, Barlow, and Still. 
Author's ease. 



MENINGITIS. 365 

of cerebrospinal meningitis, it can now be said that they are seeD very 
frequently and in large numbers in epidemics of cerebrospinal menin- 
gitis, and may occur sporadically. They are only specific, inasmuch 
as they are a form of cerebrospinal meningitis as it occurs in younger 
children and infants. 

These cases divide themselves into those which are fatal after six 
weeks; those which die after three or four months with hydroceph- 
alus ; and those which recover. In the first set of cases anatomically 
we find pus and lymph at the base of the brain and extending down 
the cord. In the second set of cases there is simply thickening of the 
pia and arachnoid, with adhesions between the cerebellum and me- 
dulla. The inflammation may spread down the cord to a varying 
degree and upward along the lining membrane of the ventricles, and 
afterward along the base as far as the optic commissure. In the 
chronic cases there may be adhesions of the meninges either in the 
anterior part of the base of the brain or even on the vertex, showing 
that this has been slightly involved. The adhesions at the base may 
unite the medulla and cerebellum and obliterate the foramen of 
Magendie or the fourth ventricle. This results in accumulation of 
fluid in the ventricles with hydrocephalus. In some cases the ven- 
tricular fluid is clear; in others it contains flakes of fibrin and pus 
and meningococci. 

As has been shown, complications in this form are rare. Occa- 
sional arthritis is found. In some cases Still has found tuberculous 
foci of the viscera, which he considers accidental. In other cases 
the middle ear may contain mucopurulent secretion, but no evidence 
of the extension of the ear disease to the brain or meninges. 

Symptoms. — The onset, as in cerebrospinal meningitis, is abrupt 
and has the same symptomatology. The most characteristic symp- 
tom clinically of these cases is the retraction of the head. This 
supervenes early and continues until death or recovery of the patient. 
Convulsions, tonic or clonic, occur early in the disease, but are less 
frequent than in meningitis, involving the superior surface of the 
brain and cord. There are rigidity of the limbs and opisthotonos, 
and an increase and diminution of this rigidity, in the course of the 
disease, with tetanic contractures of the upper and lower extremities. 
as shown in the accompanying drawings. Vomiting is one of the 
first or early symptoms, and may occur throughout the disease. After 
the disease has lasted some time the eyes have a fixed stare ; there 
may be strabismus or nystagmus ; the pupils are contracted, or later 
may be dilated. Optic neuritis is not common, though the patients 
may be blind. If the anterior fontanelle is still open, it bulges with 
the increasing hydrocephalus, and in some eases the posterior fon- 
tanelle, which may have been closed, is reopened, the sutures become 



366 THE SPECIFIC INFECTIOUS DISEASES. 

widely separated, and the children finally lay unconscious and per- 
form automatic movements with the facial muscles, mouth, and 
extremities. 

The rigidity and retraction in some cases are extreme; the opis- 
thotonos is very marked at times; at others the neck rigidity will 
relax, but on the least irritation, either of friction or otherwise, the 
opisthotonos and tetanic spasms recur (Plate XXII.). Recovery 
may take place with retrograde of most or all of these symptoms, or 
imperfectly so with hydrocephalus. In some of these cases the tem- 
perature curve at first is high, and after the disease has lasted some 
time it may drop to the normal and remain there, or rise a degree 
above the normal, at times thus simulating tuberculous meningitis ; 
or the temperature may be normal for periods of weeks and then sud- 
denly, without any apparent cause, show wide variations, with high 
temperatures during certain parts of the day and subnormal tempera- 
ture at others. Death may supervene suddenly without cause. 

Prognosis. — The prognosis is very bad. There are few recoveries, 
and in an epidemic most of these children die or develop an incurable 
hydrocephalus. 

Treatment. — The treatment at first is the same as that outlined in 
cerebrospinal meningitis; that is, an early use of the serum. In 
the chronic state the treatment is directed toward the relief of the 
hydrocephalus. As soon as this is established or evident, repeated 
lumbar puncture should be performed, in order to stay the increase 
of the fluid in the ventricles, and, if possible, effect a cure of the 
hydrocephalus ; this is not always possible. In these cases the Flex- 
ner serum is introduced into the ventricles of the brain, which are 
punctured through the anterior fontanelle. The contained exudate 
is withdrawn and the serum introduced. The operation is repeated 
on both ventricles in succession. So far the results have not been 
encouraging or conclusive. The treatment of the symptoms are the 
same as that laid down for cerebrospinal meningitis. 

Meningitis Serosa (Qttixcke) (Acute Internal Hydrocephalus). 
— Meningitis serosa, or acute internal hydrocephalus, must not be 
confounded with tuberculous meningitis, which formerly was called 
acute internal hydrocephalus. Meningitis serosa was described in 
1893 by Quincke. Four years later Bonninghaus reported some 
of these cases, and since then a number have been described in the 
literature. 

Occurrence and Definition. — It is a comparatively rare disease, and 
occurs only between the ages of one and five years. In consists 
of a serous inflammation of the extra- and intra-cerebral pia mater, 
and as a consequence of this inflammation there is an inflammatory 
oedema in the subarachnoidal space, accompanied by acute internal 




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MENINGITIS. 367 

hydrocephalus, or serous exudate in the ventricles of the brain. We 
have two forms of this condition: in one the brain and membranes 
are found to be the seat of inflammatory oedema, in which the exu- 
date in the ventricles is comparatively small in amount ; in the other. 
the more common form, there is a very large exudate in the ven- 
tricles, and the membranes of the brain and pia mater are but little 
affected. 

Etiology. — The etiology is not quite clear. Quincke insists that 
the condition may occur idiopathically, in a manner similar to an 
idiopathic pleurisy. Later authors are inclined to regard serous 
meningitis, however, as an infectious process, due to the invasions of 
staphylococci or streptococci, which are found in the ventricular fluid 
removed through lumbar puncture or postmortem. Some of these 
cases may follow a chronic hydrocephalus ; others may be traumatic 
or complicate an acute febrile disease, such as typhoid fever or 
pneumonia. 

Symptoms. — The symptoms are not always marked, and it is not 
always possible to recognize the disease with certainty. The differ- 
ential diagnosis from other forms of meningitis, such as the tuber- 
culous form, is made with the greatest difficulty. The disease may 
begin with varying symptoms. The children are peevish and restless ; 
they refuse to take nourishment. There may be constipation, dis- 
turbances of the process of digestion, and finally vomiting, with con- 
tinued emaciation. The temperature in all cases thus far observed 
is raised but little above the normal; or, if raised to 103° F., rapidly 
falls again to the normal. The pulse may be normal or slightly in- 
creased in rapidity. A constant symptom in children below fourteen 
months is that the head increases in circumference, the sutures are 
forced apart, and the anterior fontanelle becomes tense and bulging. 
The cerebral symptoms consist mostly of sopor, uneasiness, strabis- 
mus, and nystagmus. Sooner or later convulsions appear, involving 
most of the musculature or groups of muscles. In some cases an 
early optic neuritis has been observed. 

The course of the disease is a protracted one, inasmuch as the 
symptoms may extend over weeks or months, ending finally in death, 
preceded by an increasing cachexia. 

In those cases which have recovered, the circumference of the 
head has returned to its normal dimensions. 

Morbid Anatomy. — The most striking lesions found post-mortem 
are a dilatation of the ventricles of the brain with an increased amount 
of intraventricular fluid, by which the surface of the brain is com- 
pressed and the convolutions flattened. The ependyma is swollen. 
thickened, and the surface granular. The choroid plexus is hyper- 
semic. The membranes of the brain mav be dull and more or less 



368 THE SPECIFIC INFECTIOUS DISEASES. 

hypersemic. In some rare cases, at the base of the brain a circum- 
scribed purulent meningitis has been described, which supports the 
view that serous meningitis may follow a localized condition of this 
character. 

A characteristic of serous meningitis is the cloudy swelling with 
proliferation and desquamation of the cells of the ependyma, and 
cellular infiltration of the brain substance beneath the ependyma with 
round cells, especially along the bloodvessels. In such cases there is 
really an ependymitis or meningitis ventricularis. 

Diagnosis. — The diagnosis of serous meningitis must be made 
from meningitis of other varieties, especially of the tuberculous or 
cerebrospinal type. The author is inclined to believe that during life 
a very careful exclusion of every possible infection is the first step 
toward the diagnosis. It is a well-known fact that forms of otitis 
media purulenta will cause cerebral symptoms and even an increase 
in the intraventricular fluid, and such otitis is apt to be overlooked, 
unless thought of at the time a diagnosis is made. The patient, there- 
fore, would run greater danger from such an accident, and would lose 
a chance of recovery if the diagnosis of otitis or mastoid disease were 
too long delayed. 

Optic neuritis, which I have seen in two cases, may be present 
in forms of meningitis of the cerebrospinal type, although Beck puts 
much stress on this phenomenon. Lumbar puncture will aid more 
in the diagnosis than any other procedure. The puncture fluid in 
cases of meningitis serosa thus far published contained no micro- 
organisms, is of low specific gravity, generally 1.007, contains 1 to 
1.5 per cent, of albumin, and very few if any cellular elements beyond 
those of a few blood-corpuscles. On the other hand, a tuberculous 
meningitis would give a puncture fluid which, though it might in a 
certain percentage of cases be devoid of micro-organisms, would con- 
tain a number of mononuclear lymphocytes. In cerebrospinal men- 
ingitis the puncture fluid would contain micro-organisms unless the 
meningitis was of a chronic variety, in which form the micro-organisms 
might be absent. In cerebrospinal meningitis, however, a study of 
the puncture fluid would again aid us, inasmuch as it would show a 
preponderance of the polynuclear leucocytes. 

MUMPS. 

(Epidemic Parotitis.) 

Mumps is an infectious and contagious disease of the parotid 
gland, at times involving the other salivary glands as well as the 
testis or ovary. 

Etiology. — Parotitis is endemic in large cities, and frequently 



MUMPS. 



369 



becomes epidemic in schools and institutions where large numbers of 
children are congregated. It is most common among children of 
school age, because they are more exposed to infection than children 
at an earlier or later period of life. Girls and boys are attacked with 
the same frequency. It may occur in the newly born infant. The 
author has seen a case in an infant three weeks of age. 

The essential cause of mumps is unknown. Laveran and Catlin 
describe micrococci which they found in the blood and in the glandu- 
lar lymph of the parotid and testis. These micrococci were arranged 



Fig. 55. 




Bilateral parotitis. 



in twos and fours, did not stain by the Gram method, and were 1 to 
1.5 micromillimetres in diameter. Michaelis and Bein isolated an 
intracellular chain-forming diplococcus from Steno ? s*duct. The theory 
thus far advanced is that these micro-organisms gain access to the 
parotid through the duct. The period of incubation, according to 
Billiet and Lombard, may vary from seven to twenty-six days. 

Morbid Anatomy. — As the disease is rarely if ever fatal, oppor- 
tunities to determine the morbid conditions have been few. Yiivhow 
first described the condition of the gland as one of inflammatory 
serous and cellular infiltration of the intra-acinous and peri-acinons 

24 



370 



THE SPECIFIC INFECTIOUS DISEASES. 



connective tissue. The outcome is resolution; induration rarely 
remains. 

Symptoms. — There is a prodromal period, during which the pa- 
tient is attacked with chilly sensations or a chill, and sometimes with 
vomiting. There is pain in the region of the ear, and also a ringing 
in the ears and deafness. There is also a febrile movement, the tem- 
perature in some cases mounting to 104° F. (40° C). The tem- 
perature may be normal throughout the disease. There may be 
headache and loss of appetite. After these symptoms have lasted 
awhile, the face becomes swollen, as a rule on one side only (Fig. 55). 





Fig. 56. 












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Parotitis involving the submaxillary glands, lateral view. Boy, four years of age. 

This swelling gives the face an uneven contour, and is the charac- 
teristic symptom. In older children it causes a feeling of tenseness 
and pain on mastication. Sometimes patients are averse to opening 
the mouth on account of the pain. In young infants there is drool- 
ing. In the majority of cases, after the swelling has lasted three or 
four days and is subsiding, the opposite side becomes affected. In 
addition to the swelling of the parotid there is also intumescence 
of the lymph-nodes of the neck at the angle of the jaw and of the 
node on the parotid gland in front of the ear. Frequently the sub- 
maxillary glands are also swollen, giving the whole face a rounded 
contour. In most cases the general condition of the patients is good 



MUMPS. 



371 



and there is very little discomfort. Other cases have considerable 
pain and constitutional disturbance. In all my cases there was dis- 
tinct angina and swelling of the tonsils. In a newly born baby there 
was swelling of the tissues underneath the jaw and about the larynx, 
with croupy breathing indicating cedema of the mucous membrane 
of the larynx. 

English writers have described cases in which the submaxillary 
glands alone were involved, the inflammation being strictly limited 
to the glands on both sides (Fig. 56). I have seen cases of this kind. 

Complications. — The testes and epididymis in boys and the ovaries 
and glands of Bartholini in girls may become affected. There may 

Fig. 57. 




Angioma of the parotid simulating mum] 



be ardor urinre and a urethral discharge. These complications are 
not so common as the text-books declare. Hydrocele may occnr with 
the orchitis. I have seen a case of this kind in a very young infant. 
The urine may show a trace of albumin, or in very rare cases there 
may be blood in the urine. Endocarditis, pericarditis, rheumatism, 
and osteomyelitis have been reported as complications, but the author 
has never met such eases. Parotitis complicating pneumonia has 
been observed in a boy o( six years, ami in another ease otitis and 
parotitis were present at the same time. In rare eases the breasts 



372 TEE SPECIFIC INFECTIOUS DISEASES. 

and lachrymal glands are affected. Parotitis may be a complication 
of typhoid fever, measles, varicella, and influenza. 

Course. — The disease is at its height in from three to six days, and 
runs its course in from seven to fourteen days. Mild cases may last 
only two days. Severe cases are rare. These present cerebral symp- 
toms and swelling of the tissues about the neck simulating angina 
Ludovici, with considerable dyspnoea. Cases of recurrent mumps, 
continuing for from four to six weeks, are recorded. When suppura- 
tion occurs, it is probably the result of some mixed infection. 

Diagnosis.' — The diagnosis is not difficult. Uncertainty as to 
whether the parotid is affected or not will be dispelled by drawing a 
line parallel with the lower border of the jaw; the parotid swelling 
will be above the line and the lymph-nodes of the neck below it (Fig. 
57). In swelling of the mastoid region the ear is raised from the 
skull, while in parotid swelling, even if it occur behind the ear, that 
organ remains in its normal position. The swelling of parotitis 
never fluctuates, but is elastic in character. 

Prognosis. — The prognosis of mumps is good; the majority of 
cases recover without complications. If the kidneys, endocardium 
and pericardium are affected, the prognosis will be influenced by the 
course of these affections. I have never known parotitis to result 
fatally. 

Treatment. — The patients are isolated and kept in bed as long as 
symptoms are present. The parotid is anointed twice daily with 
warm oil of hyoscyamus and covered with cotton. The bowels should 
be regulated with a saline cathartic. The diet should be assimilable. 
The affection cannot be controlled by means of drugs. Pain and 
fever are treated on general principles. 

PERTUSSIS CONVULSIVA. 

(Whooping-cough.) 

Pertussis is an acute specific infectious disease, caused by a micro- 
organism, probably of the influenza group. It is characterized in 
the majority of cases by a spasmodic cough accompanied by a so- 
called whoop. 

Pertussis is not only infectious, but it is also contagious. It is 
propagated through the atmosphere in schools and public places, the 
air of which is contaminated with the specific agent of the disease. 
The micro-organism is thought to exist in the sputum and the secre- 
tions of the nasal and air-passages of the patient. The disease is 
especially contagious at the height of the attack. There is reason 
to believe that the cough of the first or catarrhal stage is highly con- 



PERTUSSIS CONVULSIVA. 616 

tagious. The sputum in the stage of decline is also capable of convoy- 
ing the disease to others, since it contains the specific micro-organism. 

Occurrence. — Pertussis prevails in all countries and climates. It 
is most frequent during the winter and spring months. It is always 
endemic in large cities, but, like scarlet fever, becomes at times so 
prevalent as to be epidemic. Pertussis is essentially a disease of 
infancy and childhood, but the individual is not exempt at any age. 
I have met it in the newly born infant. I have found the disease 
slightly more frequent in females than in males (1009 out of 1820 
cases). Twenty-two cases occurred in infants between one and two 
months of age. The majority of cases (1343) occurred between the 
sixth month and the fifth year. The disease is most frequent be- 
tween the first and the second year (404) ; next most frequent between 
the sixth and twelfth month. After the fifth year the frequency 
diminishes up to the tenth year, after which the disease is very infre- 
quent. Not every one who is exposed contracts the disease. One 
attack does not necessarily confer immunity, but cases of second 
attack are rare. It has been observed that pertussis, measles, and 
influenza frequently follow one another in epidemic form. 

Incubation. — The incubation period is variously placed at from 
two to fourteen days. 

Etiology and Bacteriology. — The essential cause of pertussis was 
believed by Deichler and KurlofT to be a protozoa-like body which 
they found in the sputum. Afanassjew and Szemetzchenko isolated 
a bacillus from the sputum. It occurred singly, in pairs or chains, 
and measured 0.6 to 2.2 micromillimetres in length. The more 
recent researches on the bacteriology of pertussis are those of Czape- 
lewski, Hensel, and Koplik. Czapelewski and Hensel described in 
1897 a non-motile "pole bacterium" or bacillus resembling the in- 
fluenza bacillus. I at the same time described in the sputum a finely 
punctate, thin, minute bacillus, 0.8 to 1.7 micromillimetres in length, 
resembling the influenza bacillus, and staining like that or like the 
diphtheria bacillus. This bacillus was found recently by Luzatto in 
cases occurring in an epidemic of pertussis in the city of Graz. It 
is classified by him as belonging to the influenza group. Positive 
proof that this bacillus is the cause of pertussis is lacking, since 
the disease has not as yet been produced experimentally. Evidence 
simply points toward a bacillus of the influenza group constantly 
found in the sputum. 

Jochmann and Krause and Bordet and Gengou have recently 
described a bacillus of the influenza group as etiological in pertussis. 
It is probable that all these micro-organisms arc of ihe same class as 
those described above. 

Morbid Anatomy. — Post-mortem examination reveals marked in- 



o74 THE SPECIFIC INFECTIOUS DISEASES. 

liammation of the nasal passages, bronchopneumonia, and empyema 
or simple fibrinous or serous pleurisy. Emphysema as a result of 
rupture of the lung-tissues has been reported by Xorthrup, who 
describes the lun&'s of an infant seven months old as beinff studded 
with cavities measuring one-half a centimetre to two centimetres in 
diameter. The lungs looked like parchment filled with bubbles. 
Hemorrhages in the eye, ear, and brain are a feature of the morbid 
anatomy of fatal cases. 

Symptoms.- — There is undoubtedly a period of incubation, but its 
length is undetermined, and it can only be said that, if the disease 
is due to the invasion of a micro-organism, some time must elapse 
between the invasion and appearance of symptoms. After the appear- 
ance of the symptoms there are three stages — the catarrhal, the spas- 
modic and the stage of decline. There is no sharp line of demarcation 
between these stages. 

Catarrhal Stage. — This stage in some children is characterized by 
a cough which is especially troublesome at night, and has sometimes 
a croupy character. The peculiar nature of the cough becomes 
apparent when after a few days it becomes more troublesome instead 
of subsiding. After four or five days it may be accompanied by 
vomiting once or twice a day, especially if the paroxysm occurs after 
meals. Examination of the chest may fail to reveal bronchitis. This 
negative sign is of great value. As the case passes into the spasmodic 
stage it is noticed that the paroxysms of coughing last longer, and 
that the child becomes red in the face and expectorates a larger 
amount of mucus than in ordinary catarrhal conditions. This period 
of cough without a whoop may last five to twelve days. I have seen 
many cases in which the whoop was absent in the whole course of the 
affection. The child had what might be regarded as a severe spas- 
modic cough followed by vomiting. Fever is present as a rule only 
during the first few days. It may be remittent and slight. If bron- 
chitis complicates this stage of the disease, there may be a daily rise 
of one or more degrees in temperature. Usually toward the close of 
the catarrhal stage the incessant cough causes slight puffiness of the 
eyelids and slight oedema of the tissues of the face. 

Spasmodic Stage. — The spasmodic stage is distinguished by the 
presence of the characteristic whoop. The cough becomes of a more 
pronounced spasmodic type. The child has distinct paroxysms, 
which begin with an inspiration, followed by several expulsive explo- 
sive coughs, after which there is a deep, long-drawn inspiration, which 
is characterized by a loud crowing called the whoop. After one 
paroxysm has ended, it may be followed by a number of similar ones. 
When a paroxysm is impending the face assumes an anxious expres- 
sion, and the child runs to the nearest person or to some article of 



PERTUSSIS C0NVVLS1VA. 375 

furniture and grasps it with both hands. The paroxysm is some- 
times so severe that the child will fall prostrate or claw the air con- 
vulsively. In the severest and most dangerous type a convulsion 
supervenes. In moderately severe types of the disease the child's 
face is red or livid, the eyes bulge, and at the end of the paroxysm 
a quantity of tenacious mucoid or mucopurulent sputum is expecto- 
rated. In other cases there is vomiting at the end of the paroxysm. 
In the intervals the face is livid or pale, or the eyelids are puffy and 
the face edematous. In some cases there are punctate hemorrhages 
on the face, especially about the eyes and temples. There may be 
chemosis of the conjunctivae as a result of the bursting of bloodvessels. 
At this period there is in the majority of cases an accompanying 
bronchitis, with slight rise of temperature during the day. At first 
the paroxysms occurring during the twenty-four hours may be few; 
in some cases they never become frequent, but as a rule they increase 
in number, so that the patient may have from twenty to one hundred 
in the twenty-four hours. This stage gradually declines, the number 
of paroxysms diminishing daily in number and severity. They may 
subside suddenly or gradually after from four to twelve weeks. The 
whoop may at times reappear. After the disappearance of the whoop 
a cough persists for days or even weeks, or it may entirely disappear 
and suddenly recur with the whoop. It is characteristic of the spas- 
modic period of the disease that the paroxysms should be more harass- 
ing at night than during the day. 

Other Symptoms. — In all cases of pertussis, even in the absence 
of complications, there is a slight increase in the number of respira- 
tions. In cases of even moderate severity the heart impulse is weak, 
and in exceptional cases the area of superficial cardiac dnlness is 
larger than normal, indicating dilatation of a moderate degree. The 
pulse is irregular in force and rhythm, and is distinctly more dicrotic 
than normal. In other words, there is a condition of heart-strain, 
which is evinced by dyspnoea (even in the absence of exertion), oedema 
of the face, and cyanosis. 

Kidneys. — In the majority of cases a trace of albumin is present 
in the urine; in others, a few hyaline casts. Blood in the urine is 
seen in rare cases. 

Blood. — Leucocytosis of the polynuclear type is usually present 
in the second week of the disease. 

Complications. — One of the most common complications of per- 
tussis is bronchitis. It may be mild or severe. In the severer form 
the smaller bronchi are affected, with accompanying bronchopneu- 
monia (Fig. 58). The physical signs are the same as in simple 
bronchitis and pneumonia without pertussis. In some r;i<es the 
bronchopneumonia pursues a subacute or persistent course. If reso- 



376 



TEE SPECIFIC IX F ECHOES DISEASES. 



lution takes place, other areas become consolidated. Emaciation is 
sometimes extreme. Emphysema is frequently present. Bursting 
of the air-vesicles may cause pneumothorax, or air may escape into 
the mediastinum and thence into the neck and into the subcutaneous 
tissue of the whole trunk. 

Hemorrhages. — During a paroxysm there may be epistaxis, con- 
junctival hemorrhage, bleeding from the ears, and petechia^ on the 
face and body. 

Nervous System. — Convulsions, either general or localized, may 
complicate pertussis. In the former case the outlook is grave, death 
taking place within twenty-four to forty-eight hours. 

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Pertussis ; disseminated bronchopneumonia in both lungs. Infant eight months of age. 

Fatal termination. 



Psychoses, such as melancholia and hallucinations, may compli- 
cate pertussis. Monoplegia, hemiplegia, or paraplegia, localized facial 
and oculomotor paralyses, sudden total blindness, deafness, cerebral 
hemorrhages, hemianesthesia, and aphasia have been observed. 

Gastro-enteritis. — Gastro-enteritis of a fatal type may ensue. 

An attack of pertussis may favor the invasion of the tubercle 
bacillus. This may have been previously present in the bronchial 
lymph-nodes or elsewhere in the body, or it may be received into the 
body during the attack, or afterward. In such cases tuberculosis of 
the lungs or other organs, such as the peritoneum, develops. 

Diagnosis. — If a cough fails to improve and is especially harassing 
at night, later in the disease becoming paroxysmal, if the face becomes 
livid during the paroxysm, if the patient vomits after coughing, per- 
tussis should be suspected and precautions taken to prevent its 
spread. As a rule, examination of the chest is negative in the first 



PERTUSSIS CONVULSIVA. 377 

stage. The absence of bronchitis and the presence of a cough of the 
character described are characteristic of pertussis. The presence of 
the whoop dispels all doubt. 

Infants who have the incisor teeth and older children may, after 
the pertussis has lasted for a week, develop an ulceration of the 
frenum of the tongue, which is called a dentition ulcer. It is caused 
by friction of the frsenum linguae with the edges of the teeth during 
the act of coughing. These ulcerations are not diagnostic of the 
disease; many cases do not show them, and on the other hand they 
frequently occur in coughs of other forms. 

Mortality and Prognosis. — The mortality of pertussis is greatest 
during the first year of life (25 per cent., Voit). Between the first 
and the fifth year it is about 5 per cent., and from this time to the 
tenth year, 1 per cent. (Monti). The occurrence of pneumonia in 
children under two years of age adds largely to the mortality. 
Rachitis or marasmus will militate against recovery. Hygienic sur- 
roundings render the prognosis more favorable. 

Treatment. — Prophylaxis. — The patient should be isolated, and 
should sleep in a large, well-ventilated room. During the day the 
unoccupied sleeping-room may be filled for an hour with the vapor of 
formalin (set free by means of a small formalin lamp). The object 
is to destroy suspended germs. If two communicating rooms are 
available, they may be occupied alternately every twenty-four hours, 
the unoccupied room being fully ventilated in the interval. In this 
way reinfection may be avoided. 

In spring and summer, if the weather is favorable, the children 
should be constantly in the open air during the day. In large cities 
the mother is directed to take the child into the park. When in the 
open air the paroxysms are usually notably lessened. The child 
should be warmly clad in winter. Sea air seems to aggravate some 
cases and benefit others. Pine woods and moderately high altitudes 
are probably the most beneficial, for the patients are not exposed to 
the unfavorable climatic conditions peculiar to the seacoast. 

Kilmer, to allay vomiting and the severity of the paroxysms, has 
recently applied a knitted band stretching from the axillae to the 
pubes ; on this is sewn a width of silk elastic so as to tightly envelop 
the abdomen. I have seen patients quite comfortable with the 
appliance. 

Medicinal Treatment— Medicinal treatment consists of inhala- 
tions, topical applications, and internal remedies. Simply to enum- 
erate all the remedies which have been proposed and used in pertussis. 
would take up the space of a monograph. Inhalation of ozone has 
been advocated by Caille. The remedy is expensive and the appa- 
ratus not readily procurable. Inhalation o( a mixture o\ '20 per 



378 THE SPECIFIC INFECTIOUS DISEASES. 

cent, nitrous oxide and SO per cent, oxygen is beneficial in cases in 
which the heart is weak. The inhalations are given with a cone for 
ten minutes twice daily. Insufflation of quinine or other drugs has 
not proved beneficial. The practice seemed to intensify the par- 
oxysms. Prior. Coggeshall, and other? have proposed the application 
of solutions of cocaine, 4 per cent, to 10 per cent., to the nares and 
throat. I have had no experience with this method, nor with the 
local application of antitussin. 

If the cough is very troublesome. I first endeavor to control it with 
full doses of antipyrin combined with tincture of digitalis. The 
digitalis, in doses of a drop or two several times daily, supports the 
heart, as is shown by the rapid disappearance of the oedema and 
cyanosis after its administration. Antipyrin is given in doses of 
grain j (0.06) for every year of age up to grains v (0.3) every three 
hours. If the cough is not perceptibly relieved by this remedy after 
forty-eight hours, I suspend its use, and give codeine in full doses 
every three hours. Codeine is to be preferred to morphine, which is 
advocated by Henoch. If vomiting is severe, the food is given in 
very small quantities in fluid form every few hours. By this method 
food is retained and absorbed, whereas a full meal is invariably 
rejected. The use of belladonna has not impressed me favorably. 
In several cases it seemed to aggravate the cough by causing a dryness 
of the laryngeal mucous membrane. Bromoform I consider danger- 
ous and of questionable utility. Quinine in full doses three or four 
times daily is a favorite remedy with many. Vaccination and the 
injection of diphtheria serum have been proposed to abort the dis- 
ease. I have had no experience with the serum treatment. In a 
word, the treatment of pertussis consists in applying the rules of 
hygiene, in mitigating the cough with antipyrin or preferably codeine, 
and in supporting the heart with digitalis. The complications should 
be treated on the principles laid down in the sections on Bronchitis, 
Pneumonia, and Pleurisy. 

DIPHTHERIA. 

Diphtheria is a contagious febrile disease which affects the throat 
and air-passages. It is characterized by the formation of a pseudo- 
membrane on the parts affected. The disease manifests itself by a 
local lesion and general symptoms caused by the entrance of toxins 
and. at times, of bacteria into the blood and lymph. 

Age and Occurrence. — Although diphtheria is uncommon in the 
newly born infant, statistics of large numbers of cases show a certain 
percentage in these subjects : thus, of 547 cases reported by Monti, 
the newlv born number 24. and in Baoinskv's statistics several cases 



DIPHTHERIA. 379 

are noted. The disease is more frequent from the first to the third 
month than from the third to the tenth month (Monti). The largest 
number of cases occur from the second to the sixth year (40 to 63 
percent.) (Monti, Baginsky). 

According to Seitz, it is slightly more frequent among boys than 
girls. Strong as well as weakly children are attacked. Children 
who suffer from nervous affections, such as poliomyelitis, are more 
likely to contract the disease than others (Baginsky). All exposed 
to infection do not contract the disease, because some individuals are 
immune. Escherich and Fischl have proved that the blood of con- 
valescents contains antitoxic elements. Cases of several attacks in 
the same individual are not uncommon. Racial peculiarities have 
no influence. 

Diphtheria is prevalent in all parts of the world and epidemics 
occur at all seasons of the year. It is more common among the 
poorer classes, not on account of uncleanliness, but as a result of 
overcrowding. 

Contagion. — Diphtheria is contagious from person to person, and 
may be conveyed by any one who has been in the room occupied by a 
patient with the disease. Mild cases may give rise to fatal cases. 
The disease is infectious, spreading through families and schools, and 
may be conveyed through the medium of sputum, hands, toys, clothes, 
and in milk. 

Period of Incubation. — This has not been determined with any 
accuracy in diphtheria. Two to eight days, or an average incubation 
of three days, is laid down by most observers, but no accurate data 
are available on this important point. Some authors place twenty 
days as an extreme limit of incubation. This latter period is evi- 
dently only founded on surmise. 

Etiology. — The essential cause of diphtheria is a bacillus, the 
Bacillus diphtherial, which was first noted in stained specimens by 
Klebs in 1882. Loffler first isolated and accurately described it in 
1884. It is present in all cases of true diphtheria of Bretonneau. 
In the 3 per cent, of cases in which it is reported absent there is good 
reason to believe that failure to establish its presence was due to 
imperfect technique. The bacillus is non-motile, twice as thick and 
about as long as the tubercle bacillus, thickened at the extremities, 
has no spores, and in some forms has been described as branching. 
It is very resistant, adheres to clothes and candy, and has been found 
in milk. It will retain vitality a long time in dried membrane 
(seventeen weeks), as has been shown by Boux and Yersin. Tt has 
been detected nine weeks after the disappearance of the membrane 
from the throat. It is found present with other bacteria, principally 
staphylococci and streptococci, pneumococci, Bacillus coli commune. 



380 



TEE SPECIFIC INFECTIOUS DISEASES. 



pyocaneus, proteus, and sprue. It has been found by Roux and 
Yersin in the throats of perfectly healthy individuals, and may be 
present without the formation of a membrane. It has been shown 
that this bacillus forms toxins of very positive action. According to 
Sidney, the toxins of diphtheria may be divided into albuminoses 
and organic acids. 

The pseudobacillus of diphtheria was first isolated by Hoffman. 
In its growth and staining properties it is identical with the true 
diphtheria bacillus, but is not virulent to animals. Roux and Yersin 
regard it as a weakened diphtheria bacillus. Others believe that it 



Fig. 59. 



Fig. 60. 













1 •.. '\F% 



'j/tAfte** 



V* 



The Bacillus diphtheria? (Klebs-Loffler). 
Fig. 59. — Pure culture, photomicrograph. Fig. 60.— Pure culture, photomicrograph, 
x 1000. x 1000. Shows the irregular beaded stain. 



bears no relation to the true bacillus. It is found associated with the 
true bacillus, and also in cases of diphtheria after this bacillus has 
disappeared from the throat (Koplik). Some authors have given 
the name pseudodiphtheria bacillus to another variety of bacilli, but 
this term should be strictly limited to the form described above. 

General Infection with the Bacillus Diphtheria? alone and with 
Other Bacteria. — The bacillus of diphtheria was first demonstrated 
by Frosch (1895) in the heart's blood, liver, spleen, kidneys, and 
lymph-nodes. Since then, Kolisko, Paltauf, Schmorl, Booker, Coun- 
cilman, Mallory, and Wright have demonstrated its presence in the 



DIPHTHERIA. 



381 



blood and internal organs in fatal cases of diphtheria. The work of 
Councilman and his pupils is the most recent and complete on this 
subject. They show that the bacillus may occur alone or in associa- 
tion with streptococci or staphylococci in the blood, lungs, liver, 
spleen, and kidney. It is more likely to be found alone in fatal cases 
of uncomplicated diphtheria. The mixed infections with streptococci 
and other bacteria occur in diseases, such as scarlet fever and measles, 
which may be complicated with diphtheria. The investigators just 

Fig. 61. 
12 3 



n 


■■'■ i 




BHB i 


■/' ***** § y' ^Ba 


m \ 






r lflH 












HH 


<IR \ 










I 1 


L 1 


fl 


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1 and 3. Cultures of the pseudobacillus of diphtheria on agar, showing the diffuse 
character of the growth. 2. Growth of Bacillus diphtheria? (Klebs-Loffler) on the same 
medium. It is a delicate growth in colonies. 



mentioned found endocarditis, bronchopneumonia, empyema, mastoid 
disease, and thrombosis of the sinuses due to the diphtheria bacillus. 
The bacillus was found also in the pus of acute abscesses in various 
localities. 

Morbid Anatomy.- — In fatal cases the membrane appears as a 
thick brownish or grayish-brown mass. It is sometimes present as 
a thin whitish pellicle, and occasionally is almost black. It may be 
friable or as resistant as cartilage, and may extend over the tonsils. 
palate, pharynx, base of tongue, epiglottis, and trachea. The areas 



382 THE SPECIFIC INFECTIOUS DISEASES. 

not covered by membrane are injected, and may be the seat of hem- 
orrhages. The tonsils are enlarged and bluish red. In the gan- 
grenous forms the tonsils, soft palate, and uvula may be converted 
into necrotic masses. The nasal passages may show membranous 
deposit. The epiglottis and vocal cords are thickened. The tracheal 
mucous membrane is hypersemic and swollen, there may be adherent 
membrane, or the pseudomembrane may be loose and curled up in 
the lumen of the trachea. 

The membrane itself has been described by Yirchow as croupous 
and diphtheritic. Councilman is of the opinion that little is to be 
gained by adhering to the old classification of croupous and diph- 
theritic membranes. Baginsky also describes forms of diphtheria in 
which the membrane possessed both croupous and diphtheritic struc- 
tural characteristics. According to Councilman, the first step in the 
formation of the membrane is a degeneration and necrosis of epithe- 
lium, preceded by a proliferation of the nuclei of the cells. Detritus 
and hyaline masses result. An inflammatory exudate rich in fibrin 
is thrown out from the underlying tissue. The fibrin forms in part 
a reticulum enclosing cells and degenerated epithelium, and in part 
a hyaline reticulated membrane. The hyaline membrane is formed 
on surfaces which are covered with several layers of epithelial cells. 
Fibrinous membrane is formed on the surface and in the tissue. By 
constant accretions thick masses are, formed. The membrane is never 
formed on an intact epithelium, but may extend over it. There is 
nothing specific in the diphtheritic membrane. The connective tissue 
and the bloodvessels beneath the membrane may be the seat of hyaline 
degeneration. The mucous glands are degenerated. 

The diphtheria bacilli are found growing in the necrotic tissue 
and in the exudation, never in the living tissue or in epithelium 
undergoing primary degenerative changes. In exceptional cases they 
may be found enclosed in pus-cells and necrotic epithelium. They 
are found in masses, and when deeply situated have been covered up 
by later formation of membrane. 

Heart. — Councilman, Mallory, and Pearce have recently described 
the myocarditis sometimes complicating diphtheria. There is a fatty 
change in foci or in more diffuse areas in the muscle-fibre. In another 
form of myocarditis there are interstitial changes, consisting of focal 
collections of plasma and lymphoid cells, and the formation of new 
connective tissue, resulting in some cases in a fibrous myocarditis. 
These pathologic changes are due to the action of the diphtheria 
toxins on the heart-muscle. 

The Lungs. — Councilman states that the most common lesion in 
fatal cases is a bronchopneumonia, lobar pneumonia never being 
present. The process begins in an infection of the atria. The bac- 



DIPHTHERIA. 383 

teria found in the lung, and which are present independently of the 
character of the lesion, are the pneumococcus (rarely), Streptococcus 
pyogenes, and the diphtheria bacillus. Marrow-cells are found in the 
capillaries, and thrombi in the larger vessels. The lymphatics are 
dilated and contain fibrin and cells. 

Spleen. — The spleen macroscopically is normal; microscopically, 
the lymph-nodules are more prominent than is normal, and contain 
foci of epithelioid cells. The vessels are the seat of hyaline degen- 
eration, and in the later stages contain large numbers of plasma-cells. 
Some of the nodes, may be the seat of necrosis and abscess. 

Liver. — The changes in this viscus are due to the action of toxins, 
and consist of parenchymatous degeneration and necroses, seen espe- 
cially in the centre of the lobules. There is slight hyaline degenera- 
tion of the capillaries. 

Kidneys. — There may be simple degeneration or acute nephritis. 
The severe forms of nephritis are found in the cases which are quickly 
fatal (Councilman). The interstitial and glomerular changes are 
more common in older children and in protracted cases. There is no 
specific form of nephritis in diphtheria, and all the changes are due 
to the action of toxins. 

Lymph-nodes. — The mesenteric lymph-nodes, the nodes at the 
angle of the jaw and in the retropharynx and oesophagus are enlarged, 
and may undergo necrotic changes (Flexner). Councilman, Mallory, 
and Pearce describe the changes in the lymph-nodes as being more 
marked in those nearest the lesion. There are congestion, hemor- 
rhages, and diffuse and circumscribed necrosis. In addition there 
is a formation of foci resembling miliary tubercles, and composed 
of epithelioid cells which undergo degeneration, forming granular 
detritus. Bacteria are not found in the nodes. The changes are due 
to the toxins. 

Nerves. — There are fibrillation, increase of the cells of the sheath 
of Schwann, fatty degeneration of the axis-cylinder, hemorrhages, 
and nodular degeneration of the nerve-sheaths. In the spine there 
are infiltration of the meninges, hemorrhages, and degeneration of 
the anterior horns. Degenerative oculomotor changes are present. 
There are dilatation and round-cell infiltration around the central 
canal of the cord. 

Stomach. — Diphtheritic membrane in the stomach occurring in 
cases of diphtheria has been described by Smirnow and Councilman. 
Of 220 cases reported by the latter, 5 showed the presence of mem- 
brane to a greater or less extent. The membrane either covered the 
whole surface or formed patches or streaks over I lie rugse. The 
mucous membrane was swollen, hypersemic, or hemorrhagic. 

The Middle Ear. — Of 144 cases reported by Councilman. Aial 



384 THE SPECIFIC INFECTIOUS DISEASES. 

lory, and Pearce, 86 showed involvement of the middle ear on one or 
both sides ; in 7 the mastoid was affected. The inflammatory products 
were serum or pus. The organism most constantly present was the 
streptococcus, but the diphtheria bacillus has been found, as have also 
the staphylococcus and pneumococcus. 

The Blood. — The specific gravity is increased at the height of the 
disease. In mild cases it is not perceptibly changed ; in severe septic 
cases it may range from 1054 to 1060 (Baginsky). Haemoglobin is 
reduced only in severe cases of protracted course. Leucocytosis is 
not marked in mild cases, but in severe septic forms an increase of 
the white blood-cells has been observed by Felsenthal and Monti. In 
malignant cases there is a reduction in the number of red blood-cells 
(Ewing, Billings, Morse). 

Symptoms. — Clinically, it is convenient to divide diphtheria into 
the purely local forms with few constitutional symptoms, the local 
forms with symptoms of marked toxaemia or septic forms, and the 
laryngeal forms. 

Purely Local Forms with Slight Constitutional Disturbances. — 
In diphtheria sine membrana, cynanche contagiosa (Senator), or 
catarrhal diphtheria, there may be no formation of membrane, the 
fauces showing only an angina of varying severity. In some cases 
there is the picture of a follicular or lacunar amygdalitis. Macro- 
scopically there is nothing to show that the process is diphtheritic 
( Plate XXIII. ) . In other forms the membrane is present on the tonsils 
as specks or strips of exudate, or white or greenish pultaceous masses 
which may extend to the uvula, or there may be spots or extensive 
plaques on the posterior pharyngeal wall. In other mild cases the 
process is confined to a small necrotic excavated area in one or the 
other tonsil, as described by Henoch. In still other forms the mem- 
brane may cover both tonsils, and extend over the soft palate and 
pillars of the fauces. In these forms of localized diphtheria the nares 
are seldom involved. 

In these localized forms of diphtheria the infant or child may 
present few symptoms pointing to the throat affection. Unless the 
physician be systematic in his methods of examination, he may fail 
to inspect the throat at his first visit, and the diphtheria may thus 
escape detection. The nursling in this as in the non-diphtheritic 
affection, may refuse to take the breast. The movements are green- 
ish, and have an offensive odor, or may be diarrhoeal. There are 
fever and restlessness. Inspection will reveal slight or marked swell- 
ing of the lymph-nodes at the angle of the jaw. The temperature 
may not be above 101° F. (38.3° C.) or may be as high as 105° F. 
(40.5° C). As a rule, it is not persistently high. The pulse is 
accelerated and the respirations slightly increased. 



PLATE XXIII 






GfDupu 



pay 



l. Tonsillar Diphtheria, with a small patch of membrani 

on the uvula. 
2. Tonsillar Diphtheria, with a patch of membrane on th< 

pillars of the fauces. 
8. Acute Follicular Amygdalitis, which may he diphtheritic 



DIPHTEEEIA. 385 

The invasion of the disease is for the most part insidious in 
nurslings ; rarely is there a chill or convulsion. The tonsils are en- 
larged, and show small specks or plaques of membrane on their sur- 
face. The uvula may be red and swollen, and there may be patches 
of membrane on the sides adjacent to the tonsils. There is sometimes 
a croupy cough. In purely local diphtheria, however, the larynx is 
not involved in the majority of cases. The urine may show a trace 
of albumin, and in some cases a few leucocytes, blood-cells, and a 
very few hyaline casts. In older children the signs of illness are 
more marked. They complain of pain on swallowing, and the tem- 
perature may at first be high. Toxsemic symptoms, such as pain in 
the joints, headache, pain in the back, and slight prostration, are 
present. Inspection of the throat may show the tonsils to be enlarged, 
and to present the appearances mentioned above. Other members of 
the family may complain of sore throat. I have reported cases in 
which children complained of but few symptoms and engaged in their 
customary play. Examination of their throats disclosed the presence 
of simple inflammatory redness and swelling of the tonsil, pharynx, 
and uvula. In these cases the diphtheria bacillus was detected in 
scrapings from the fauces. Membrane never developed, and yet they 
were cases of true diphtheria. 

The fever is not characteristic. The temperature may at first 
reach 104° F. (40° C.) or above, and gradually drops to the normal 
with subsidence of the symptoms. Otitis and suppuration of the sub- 
maxillary and retropharyngeal lymph-nodes may cause the tempera- 
ture to become remittent or intermittent. 

Septic Form of Diphtheria. — In the second clinical form of 
diphtheria there are in addition to the local symptoms present in 
the first form, constitutional symptoms of a severe or even septic type. 
The children at the outset appear very ill ; the temperature is high, 
there is marked restlessness with a tendency to drowsiness, the face 
is flushed, and the breathing noisy or nasal. The infants refuse the 
breast or bottle, and older children complain of great pain in swal- 
lowing. In some cases the glands at the angle of the jaw are swollen, 
and the neck is more rotund than normal. Inspection of the throat 
shows the membrane on the tonsils, or on both uvula and tonsils. It 
spreads rapidly, the tonsils, soft palate, and pharynx being covered 
in one or two days. The membrane may break down, and masses of 
necrotic tissue be expectorated. In severer forms the membrane 
extends over the posterior nares, and gradually invades the nasal pas- 
sages. At first a slight nasal serous discharge is noticed, which in- 
creases in amount and becomes ichorous and tinged with blood : the 
anterior nares become eroded and are coated with a whitish or greenish 
membrane. In some cases the membrane involves the buccal mucous 

25 



386 THE SPECIFIC INFECTIOUS DISEASES. 

membrane. There is severe stomatitis, the lips are eroded, and the 
angles of the month may show rhagades covered with membrane. 
With the development of these symptoms the toxaemia increases ; the 
fever may be moderate, not exceeding 102° or 103° F. (38.8° or 
39.4° C.) ; the pnlse is rapid and feeble; the sensorinm somewhat 
benumbed. The lymph-nodes at the angle of the jaw may be much 
enlarged, and the tissue underneath the jaw may be the seat of phleg- 
monous inflammation. The breath has a very fetid odor. The urine 
may reveal the presence of albumin, a slight amount of blood, and a 
few casts of the hyaline or epithelial type. 

The constitutional symptoms may diminish in severity, and with 
the subsidence of the local symptoms the appetite returns, the sen- 
sorium brightens, and recovery gradually takes place. On the other 
hand, if a fatal issue occurs, it results from heart paralysis, paralysis 
of the general nervous system and respiratory function, or extension 
of the diphtheritic process to the larynx, trachea, and lungs. 

If the diphtheria extends to the larynx, the voice becomes first 
husky, then croupy. The breathing is labored and of the laryngeal 
or croupy types, there is retraction of the suprasternal notch and epi- 
gastrium, the accessory muscles of respiration are drawn into play, 
and unless relieved the patient dies of suffocation. Even if relieved, 
when the septic symptoms and toxaemia are severe the patient may 
succumb or the process may spread downward, and involve the trachea 
and lungs. In those cases in which there is cardiac paralysis, vom- 
iting and abdominal pain supervene. The patient is pale and the 
surface cool. Gallop rhythm sets in and the heart-sounds become 
indistinct. The expression is at first anxious, then apathetic; the 
voice is scarcely audible; the patients no longer notice their sur- 
roundings. Death ensues from pulmonary oedema with symptoms of 
heart-failure. 

If the general nervous system is involved, paralysis of the soft 
palate sets in even after the membrane has disappeared from the 
tonsils and pharynx. The reflexes are absent, and the child is unable 
to sit upright. The act of swallowing not only becomes difficult, but 
fluids may find their way into the larynx and thence into the trachea, 
causing pneumonia ; or the paralysis may extend to the diaphragm, 
when the lethal issue is hastened by paralysis of the respiratory 
apparatus. 

The Malignant Septic Form. — This form has been partly de- 
scribed above. It is characterized not only by the malignancy of the 
local process, but by the severity of the toxemic symptoms as well. 
It was formerly believed that these cases were due to mixed infections 
with streptococci and staphylococci, but it is now known that the 
Bacillus diphtherise alone may cause all the symptoms. In these 



DIPHTHERIA. 387 

cases not only the toxins, but the bacillus itself enters the circu- 
lation. The pharynx, tonsils, and nares are covered with a dirty 
brown or greenish membranous exudate. There is an ichorous dis- 
charge from the nares. The tonsils, pharynx, and lymph-nodes of 
the neck become necrotic. The membrane is discharged from the 
nose and mouth. The fetor of the breath is extreme, and the pros- 
tration correspondingly great. The larynx, trachea, and lungs may 
be involved in the diphtheritic process. The pulse is weak and rapid. 
The temperature may not be above the normal, and in some cases 
may be subnormal. Acute nephritis may be present. In some cases 
hemorrhage under the skin and from the nose, mouth, bowel, and even 
kidney, may precede death. 

A few cases recover, but in them the necrosis of tissue in the 
pharynx and larynx causes permanent defects and cicatricial con- 
tractures. Loss of the uvula and perforations of the soft palate may 
result from diphtheria in early life. 

Laryngeal Diphtheria. — Laryngeal diphtheria (croup) is the re- 
sult of the extension of a mild or severe tonsillar or pharyngeal diph- 
theria. There may be no preceding clinical manifestations. There 
are the rare cases of so-called ascending croup, whose existence has 
not been wholly disproved. Cases are seen in which the most careful 
inspection has failed to detect preceding disease of the pharynx, epi- 
glottis, or tonsils. Lastly, there is a class of cases which occurs 
during convalescence from pharyngeal or tonsillar diphtheria. 

The symptoms vary accordingly as the disease manifests itself 
first in the larynx or follows a localized tonsillar or pharyngeal diph- 
theria. In the latter case there may be slight redness of the tonsils 
or pharyngeal mucous membrane, or the parts above the larynx may 
show "membranous deposits. In either case the laryngeal invasion 
is ushered in by croupy cough and stridulous or metallic breathing. 
The cough is harassing and persistent, and the stridor increases within 
twenty-four or forty-eight hours to such an extent as to be distinctly 
audible, and to give the impression that there is a mechanical obstruc- 
tion in the larynx. The breathing becomes labored, and there is 
retraction of the parts above the sternum and of the peripneumonic 
groove, especially at the epigastrium. In rachitic infants the sides 
of the chest and the epigastrium are markedly retracted at each descent 
of the diaphragm. With increasing obstruction the face assumes an 
anxious expression, the lips become cyanosed, and the surface cool. 
The pulse is rapid — 120 to ISO. The fever may be high or low. 
The lividity of the face in the severer forms o\' dyspnoea gives place 
to pallor. The picture of laryngeal obstruction, with the stridulous 
breathing, increased respirations, and overact ion of the accessory 
muscles of respiration, is so characteristic as to be significant to evt n 



388 THE SPECIFIC INFECTIOUS DISEASES. 

the inexperienced observer. During the paroxysms of coughing 
membranous casts are expelled from the larynx. The membrane 
may extend downward, involving the trachea and bronchi, casts of 
which may be expelled. The lungs may become involved, and in 
severe cases are the seat of a bronchopneumonia of streptococcic 
nature. . With this there may be compensatory emphysema. The 
urine may show the existence of slight or extensive nephritis, or may 
be normal in every respect. 

Especially deceptive are those cases of membranous laryngeal 
diphtheria or croup whose onset closely resembles that of so-called 
catarrhal laryngitis. In these the symptoms may develop suddenly, 
and within twenty-four hours the patient presents all the symptoms 
of laryngeal obstruction (croup d'emblee of the French). Inspec- 
tion may show little variation from the normal appearances in the 
pharynx. We should be cautious not to assume that no membrane 
is present in the larynx. Cases have been recorded in which laryn- 
goscopy examination failed to show membrane in the larynx, but 
in which postmortem it was found beneath the cords and in the 
trachea. 

Course and Duration. — In the mildest and purely local forms the 
disease reaches its height in from two to four days ; the temperature 
then drops to the normal and convalescence is established. In the 
severe septic forms the membrane spreads from the tonsils to the 
pharynx, and the disease attains its full development in from five to 
eight days. The temperature falls by lysis or crisis, and convales- 
cence is established. If the case is very severe, the disease shows no 
tendency to limit itself, the toxsemia is extreme and the involvement 
of the lymph-nodes is very great. Death may ensue in from a week 
to fourteen days. In some very malignant cases death may ensue in 
from three to four days after the onset of the disease. The laryngeal 
diphtheritic croup reaches its full development as a rule early — 
within three days. The disease may then retrograde under treat- 
ment or may advance into the trachea and bronchi, and cause death 
in a variable length of time. 

Complications. — The complications include bronchopneumonia, 
pleuritis, gastro-enteritis, retropharyngeal abscess, suppuration or 
necrotic destruction of the lymph-nodes of the neck, nephritis, cardiac 
paralysis, early and late (or post-diphtheritic) general paralysis, and 
diphtheria of the eyes, skin, and vulva. 

Bronchopneumonia and Pleuritis. — Bronchopneumonia is found 
in from 50 per cent. (Baginsky) to 80 per cent. (Talamon) of the 
autopsies on children who have died of diphtheria. It results from 
extension of the disease from the trachea into the smaller bronchi and 
alveoli of the lung, and is therefore always a true bronchopneumonia. 



DIPHTHERIA. 389 

Through the investigations of Loffler, Flexner, Northrup, and Prud- 
den, it has been proved that the diphtheria bacillus, the Streptococcus 
pyogenes, the Staphylococcus pyogenes, and the pneumococcus are the 
exciting causes of the pneumonia. In the pneumonia resulting from 
the diphtheritic or pseudodiphtheritic processes complicating scarlet 
fever and measles, Prudden and Northrup have shown that the Strep- 
tococcus pyogenes is an active causal agent. The onset of a compli- 
cating pneumonia is generally indicated by an exacerbation of the 
dyspnoea, fever, and cough. The prostration is also more marked. 
Auscultation of the inferior lateral or posterior parts of the chest on 
one or both sides reveals the presence of bronchopneumonia ; while 
resolution is taking place in one part of the lung, other areas are being 
involved. Thus an apparent improvement may be followed by a 
rapid rise of temperature, increased dyspnoea, and rapid pulse. This 
form of bronchopneumonia may be complicated by pleuritis of a 
serous, serofibrinous, purulent, or hemorrhagic type. 

Gastro-enteritis. — In nurslings there is frequently a diarrhoea 
with green stools and vomiting. In some cases these symptoms may 
become severe. Extension of the membrane into the oesophagus, 
stomach, and gut may take place, with a fatal result. The cases of 
simple diarrhoea are directly due to the swallowing of bacteria from 
the mouth and fauces. The diarrhoea may be so severe as to become 
one of the leading features of the disease. 

Retropharyngeal Abscess. — Ketropharyngeal abscess occurs in the 
tonsillar and pharyngeal forms of diphtheria as a result of infection 
of the retropharyngeal lymph-nodes by streptococci. 

Nephritis. — Nephritis may be absent, slight, or severe. Eaginsky 
found it present in 42 per cent, of his cases. In the majority of cases 
of even mild diphtheria there is albuminuria ; in some the urine may, 
in addition, contain casts, blood-cells, renal epithelium, and leucocytes, 
showing grave lesions of the kidneys. 

The affection of the kidneys is brought about by the action of 
the toxins on the parenchyma of the kidney. Not only are toxins 
produced in the kidney substance, but bacilli have been found in the 
kidney and in the urine. A large percentage of the cases of nephritis 
are of the mild type. Here, as in scarlet fever, we have cases in 
which there is nephritis with blood-casts and ura?mic symptoms in the 
course of the disease, and cases in which there is total suppression. 
All are agreed that oedema and anasarca of the body are uncommon, 
even in the presence of severe nephritis. T have seen severe septic 
forms of pharyngeal diphtheria ushered in with vomiting and ursemic 
symptoms, such as headache and exhaustion, before the appearance 
of the membrane. These symptoms subsided when the membrane 
was fully formed, to be followed in a few days by complete snppres- 



;>90 THE SPECIFIC INFECTIOUS DISEASES. 

sion of urine after the disappearance of the membrane. In one of 
my eases the membrane had entirely disappeared from the throat and 
the patient was apparently convalescing when total suppression set 
in, continued for several days, followed by uraemic convulsions and 
death. 

Heart Paralysis. — Of greatest clinical significance is the cardiac 
diphtheritic paralysis, which may become apparent either ear]y in 
the disease or later on in convalescence. The early form may set in 
while the membrane is still visible in the throat. It occurs in the 
septic forms of the disease. These are the severe cases. The chil- 
dren show great prostration and apathy; the pulse is rapid and 
irregular ; the heart-sounds, especially the muscular sounds, are indis- 
tinct; the pulse is feeble and flickering; there are vomiting and 
abdominal pain. 

These symptoms may repeat themselves in attacks, until finally 
the patient dies with all the symptoms of collapse, such as cool ex- 
tremities and shallow respirations. In such cases there is, as a rule, 
a marked nephritis. In the late cases the symptoms of cardiac failure 
appear from the second week of the disease to the seventh week of 
the convalescence. The membrane has disappeared from the throat. 
There may be no premonitory symptoms, or there may have been a 
slight blowing murmur at the apex. In their mildest form the heart 
symptoms appear in the second or third week. The heart becomes 
irregular, and the muscular sound is weak ; the pulse becomes small 
and either slow or rapid (tachycardia). There may be attacks of 
syncope, during which the patients vomit, complain of abdominal 
pain, and refuse medicine and nourishment. Sudden cardiac failure 
and death without symptoms, premonitory or otherwise, may occur in 
the period of convalescence. 

Mild forms of cardiac irregularity which do not eventually prove 
fatal are seen in the beginning of convalescence. There are forms 
of cardiac irregularity which may appear alarming at first and in 
which complete recovery results. Thus, as will be seen under the 
heading of Myocarditis, it is not uncommon in the convalescence, 
early or late, to observe the heart become irregular. This irregu- 
larity increases from day to day. In its most pronounced form I 
have observed it in a child three years of age, in whom the heart 
would contract two or three times, there would then be a pause, fol- 
lowed by a two or three or four contractions. The pulse varied from 
80 to 96 during sleep, and 110 to 130 in the waking state. The 
compressibility of the pulse varies in these cases; the heart-beat is 
weak, or at times may be strong. The second sound will be accen- 
tuated at the pulmonary orifice. In these cases the child is apparently 
comfortable. There is no pericardial distress, pain, or vomiting; 



DIPHTHERIA. 391 

there may be occasional sighing. The cardiac irregularity may per- 
sist for days, even weeks, and ultimate recovery result. It is not 
always in the severe cases of diphtheria that these symptoms of car- 
diac disturbance appear, but often in the apparently mild cases of 
short duration. 

The severe forms of cardiac paralysis set in with symptoms of 
the early cases. These symptoms may have been preceded by the 
milder symptoms of cardiac irregularity. There is slight albumi- 
nuria. Suddenly, while in apparent good health, the patients com- 
plain of dyspnoea and pain in the stomach. The lips become cyanosed 
and the extremities cool, the pulse thready, the heart impulse weak, 
the heart-sounds scarcely audible; the heart may be rapid or as slow 
as 40 to 50 beats per minute. Vomiting is repeated, and in some 
cases the liver is enlarged, as also the spleen. In all cases of diph- 
theritic myocarditis the enlargement of the liver and spleen with the 
increase of the pulse rate is a symptom of very serious moment, and, 
as a rule, a precursor of a fatal issue. The patients may survive one 
or two such attacks, only to succumb finally. In the early forms of 
cardiac paralysis there may be no gross lesions in the heart-muscle. 
In the later forms the lesions are more apparent. There are fatty 
parenchymatous changes. In other cases there may in addition be 
changes in the vagi. 

Diphtheritic Paralyses. — Paralyses are the result of the action of 
the toxins of the Bacillus diphtheria? on the nerve-trunks and tissues 
of the general nervous system. The paralysis may occur in the course 
of the disease or during convalescence. When the paralysis occurs 
early, it affects the velum pendulum palati. In cases which result 
fatally the heart becomes affected, pneumonia caused by the passage 
of food into the larynx develops, or the paralysis may become general. 
In the latter case the symptoms are similar to those seen in the post- 
diphtheritic forms of paralysis. This form of paralysis manifests 
itself from the second to the sixth week after the onset of the disease. 
In mild forms, it may begin with a paralysis of the muscles of the 
soft palate, which remains localized. The child has a nasal tone of 
voice, and liquid food is regurgitated through the nose on swallowing. 
In severe cases there are in addition loss of the patellar reflexes, ataxic 
conditions, inability to sit upright or to stand, oculomotor paralysis. 
facial paralysis, pallor, weak heart, arrhythmia, loss of appetite, and 
albuminuria. 

Eecovery may take place even when there is general involvement 
of the muscles. The great danger is extension of the paralysis to the 
diaphragm. Post-diphtheritic paralysis occurs in 5 to 7 per cent, of 
the cases of diphtheria, according to Baginsky, who reported 131 
cases of paralysis in 2300 cases o( diphtheria. The soft palate was 



392 THE SPECIFIC INFECTIOUS DISEASES. 

most often affected. Among the other forms of paralysis are those 
of the facial and oculomotor nerves, the larynx (recurrent laryngeal), 
and lastly forms of ataxia. Antitoxin has little effect in preventing 
these paralyses. They occur as frequently after its administration 
as during the pre-antitoxin period. 

In the American Pediatric Society's tabulation 9.7 per cent, of 
the cases had paralysis; of these, 32 out of a total of 328 cases died 
of cardiac paralysis. 

Hemiplegic cerebral palsy may occur in diphtheria (Monti, Levi, 
Baginsky ) . 

Disturbances of the Sensory Nerves. — Disturbances of the sensory 
nerves also occur in diphtheria, such as perversions of the senses of 
smell and taste ; also ansesthesia of the rectum. 

Psychical Derangements. — Psychical derangements such as mel- 
ancholia have been reported. 

Diphtheritic Ophthalmia. — True diphtheritic ophthalmia occurs 
both as an accompaniment of diphtheria of the fauces and as a pri- 
mary affection. There are two distinct forms of pseudomembranous 
affection of the eye. In the first, the Loftier bacillus is present, but 
in the second, or diphtheroid form, it is absent, and the streptococcus 
alone is found. Of the true diphtheritic form, one class of cases has 
a mild clinical course. In these the bacillus isolated resembles the 
pseudodiphtheria bacillus in not possessing virulent properties. In 
the other form of diphtheritic eye affection the membrane spreads 
rapidly and causes destruction of the eye. 

The diphtheritic invasion is ushered in with redness and chemosis. 
The membrane appears first on the palpebral conjunctiva, and causes 
marked swelling of the lids. There is little seropurulent discharge. 
In the progressive form destruction and perforation of the cornea 
result. I have seen several cases in connection with fatal diphtheria 
complicating measles, and also cases in which there was no history 
of diphtheria in the patient or family. I have seen it occur as a 
primary affection in nurslings. According to Baginsky, diphtheritic 
ophthalmia occurs in 3 per cent, of the cases of diphtheria, and is 
most frequent from the second to the sixth year. 

Diphtheria of the Shin. — Diphtheria of the skin occurs when the 
specific bacillus finds lodgment in an abrasion or cut. The mem- 
brane spreads over the wound and encroaches on the surrounding skin. 

Diphtheria of the Vulva. — Diphtheria of the vulva is met with 
both as a primary affection and as a complication of true diph- 
theria elsewhere in the body. I have not found the Klebs-Lomer 
bacillus in a number of pseudomembranous inflammations of the 
vulva and vagina in infants. Some of these cases show the presence 
of true membrane; others begin as aphthous ulceration and develop 



DIPHTHERIA. 393 

membrane later. These cases are benign. The diphtheritic bacil- 
lary cases may be divided into two distinct classes according to their 
causation. The cases of one class show the Loffler bacillus, but are 
benign in course, although I have proved by animal experiment the 
presence of the bacillus of diphtheria in virulent form. In the other 
class of cases there is extensive destruction of tissue, and sometimes a 
fatal result. Cases of this class occur as a complication of diphtheria 
elsewhere in the body or in connection with the exanthemata. 

The symptoms of diphtheria of the vulva and vagina may be 
localized strictly to the parts, or there may, as in the severer forms, 
of Henoch, be constitutional symptoms of toxsemia. Locally, the dis- 
ease is characterized by the appearance of patches of membrane on 
the inner surface of the labia, clitoris, and introitus vaginse. The 
parts, especially the labia majora, are intensely swollen and cedema- 
tous. In Henoch's cases there was gangrene or necrosis of neighbor- 
ing tissues. In my cases there was no complicating diphtheria of 
other parts. The cases occurred in infants and in children under two 
years. They were benign in course, although of bacillary type. 

Nasal Passages. — Councilman, Mallory, and Pearce call attention 
to the frequency of invasion of the accessory sinuses of the nose and 
antrum by the diphtheritic process. They found the antrum affected 
in 33 cases of 52 examined. Clinically, this affection is more com- 
mon than appears from these figures. This would account, according 
to these authors, for the persistence with which diphtheria bacilli 
continue in the nasal secretions after the throat lesions have disap- 
peared. The disease of the antrum may, as pointed out by Wolff, 
and recently by Mayer, persist after the diphtheria has run its course. 
Mayer classifies the symptoms as eversion of the lower lid, fistulous 
opening in the cheek from which pus exudes, and a fetid purulent 
discharge from the nose on the side of the face at which the fistula 
is situated. 

Other Complications. — Diphtheria in pertussis is a serious com- 
plication, since the resistance of the patient is generally much de- 
creased. Bronchopneumonia is especially to be feared. In tuber- 
culosis the patient usually dies as a direct result of the complication. 
In measles the diphtheritic process is a grave complication ; it may 
invade the larynx and death may ensue from extension of the disease 
to the lungs. In typhoid fever the process causes death by invasion 
of the lungs. 

Exanthem. — Is there an exanthem characteristic of diphtheria 1 
I am inclined to view all eruptions which may occur in the course of 
this disease as purely accidental. They may be the result of reme- 
dies (antitoxin) administered or of some infection originating in the 
gut. Among these eruptions are the various forms of erythema and 
roseola. Erythema urticatum is often seen. 



394 THE SPECIFIC INFECTIOUS DISEASES. 

Diagnosis. — The diagnosis of diphtheria must be considered in its 
clinical and bacteriological aspects. Clinically the characteristic and 
ever-present lesion is the membrane. This is seen on the tonsils, 
uvula, pillars of the fauces, and the posterior pharyngeal wall. Its 
color varies. In consistency it may vary from a thin pellicle or 
cloudy discoloration to a thick adherent, pultaceous or stringy mass. 
In a large proportion of cases the presence of the membrane and 
other characteristics are presumptive evidence of diphtheria. On 
the other hand, there are certain forms (not very frequent) of pseudo- 
membranous inflammation of the tonsils and fauces which are not 
truly diphtheritic; these are called pseudodiphtheria or diphtheroid. 
In these cases the Klebs-Loffler bacillus is not found, but strepto- 
cocci, staphylococci, and other bacteria are present. Some forms of 
diphtheria show at first only fibrinous specks on the tonsils ; in others 
there are small necrotic ulcerations on the tonsil, and in still others 
the diphtheria may simulate an acute catarrhal follicular amygdalitis 
or lacunar amygdalitis. These cases are not as infrequent as was 
formerly supposed. In the pseudomembranous and other forms of 
inflammation of the throat above described a bacteriological test 
should always be made. It should be practised as a routine pro- 
cedure in all cases of angina. Cultures should be made in cases 
of laryngeal inflammation in which no membrane is visible in the 
fauces. If membrane be present in the fauces, and a culture fail to 
reveal the Klebs-Loffler bacillus, a second and even a third culture 
should be made. I have frequently established the presence of the 
specific bacillus in membrane in cases in which the first culture-test 
proved negative. It is not a reliable nor satisfactory method to 
spread membrane or secretion from the throat direct on a cover-glass, 
and decide from such a preparation the nature of the process. 

The technique of culture-tests is scarcely within the scope of this 
work. It is sufficient to state that growth can be obtained within 
four or five hours if the culture-tube is subjected to a temperature of 
100.4° to 102.2° F. (38° to 39° C.) in a small incubator. Other 
diseases, such as membranous forms of stomatitis, may simulate diph- 
theria. In these cases the culture test is the only positive mode of 
making a diagnosis. Certain forms of laryngismus stridulus resem- 
ble acute diphtheritic laryngitis, or a diphtheritic process may be 
present in the larynx in a rachitic infant subject to attacks of laryn- 
gismus. Cultures should be made in all such cases. 

In small towns and country districts the practitioner without the 
aid afforded by laboratories will often be thrown on his own resources 
in making a diagnosis. In such cases the following clinical symptoms 
may be considered fairly presumptive evidence of diphtheria: 

The presence of membrane on a tonsil and a small patch, streak, 



DIPHTHERIA. 395 

or speck of membrane on the adjacent surface of the uvula or tip of 
the uvula; a patch of membrane on the tonsil and an accompanying 
patch on the posterior pharyngeal wall; the presence of a croupy 
cough and stridulous breathing with small patches of membrane on 
the tonsil or epiglottis, are all of much diagnostic value. The 
presence of albumin in the urine is of little value in making a diag- 
nosis, as it may be present in non-diphtheritic affections and absent 
in diphtheria. Constitutional symptoms are only of corroborative 
value. 

It is well known that the most virulent forms of diphtheria may 
at first be manifested by few constitutional symptoms. The tempera- 
ture-curve is not characteristic. If a patient who at first suffers from 
a catarrhal tonsillitis or pharyngitis, shows within twenty-four hours 
minute patches of membrane either on the uvula or pharynx, it may 
reasonably be assumed that true diphtheria is present. An acute 
laryngeal inflammation, croupy cough, and stridulous breathing 
which not only persist beyond the first twenty-four hours or first 
night, but also become aggravated, justify a diagnosis of diphtheria 
of the larynx, although no membrane is visible in the throat. Gen- 
eral symptoms are of little diagnostic value. Rhinitis at first accom- 
panied by a serous and later by a fetid sanguinolent discharge, with 
glandular swellings in the neck, is diagnostic of diphtheria. 

Adenitis is frequently absent at the outset of tonsillar diphtheria, 
even when patches of membrane of some size are present. On the 
other hand, a simple catarrhal tonsillitis is often accompanied by 
marked adenitis. 

Paralysis of the soft palate, appearing in the course of a severe 
or mild pseudomembranous tonsillar, pharyngeal, or laryngeal inflam- 
mation, or after the affection has run its course, points strongly to 
true diphtheria, although cases of paralysis of the soft palate follow- 
ing diphtheroid have been reported. The color of the membrane, its 
dctachability, and the fact that a bleeding surface is left after its 
removal, cannot be relied upon as aids to diagnosis, in view of the 
fact that interference with the membrane is not advisable. 

Aphthae with pseudomembrane over the vault of the hard palate, 
spreading to the gums and cheeks, are seen in newly born and older 
infants. These forms of pseudomembranous stomatitis are the result 
of traumatism inflicted by the infected fingers of the nurse or mother, 
and are limited to the parts on which they are first seen. Such septic 
membranes rarely spread unless the exciting causes are perpetrated. 

Herpes of the pillars o( (he fauces, so-called herpes ot the tonsils. 
are often mistaken for diphtheritic patches. With a suitable light 
such an error should seldom be made. 

Following the ingestion of caustic alkali or the traumatism con- 



396 THE SPECIFIC INFECTIOUS DISEASES. 

sequent on washing or rubbing the mucous membrane, aphthous 
ulcerations, which closely simulate diphtheritic membranous patches, 
are prone to appear over the hamular process of the palate bone. The 
history of the case, the absence of diphtheria elsewhere, and the result 
of a culture test will exclude diphtheria. 

The patches of necrotic tissue seen on the tonsils, pillars of the 
fauces, and uvula following tonsillotomy and ablation of adenoids, 
and sometimes accompanied with paralysis, may mislead the observer 
and cause him to make a diagnosis of true diphtheria. 

The membranous patches which appear on the tonsils of scarlet 
fever patients at the outset of the disease are for the most part diph- 
theroid. Unless the patient has been exposed to a double infection, 
which is infrequent in private practice, the patches of membrane 
which appear later in the disease are also of a diphtheroid nature. 
True diphtheria may coexist with scarlet fever (Baginsky, Escherich, 
Councilman), but does so in only a small number of cases. 

The appearance of a pseudomembranous exudate on the tonsils of 
a patient attacked with measles should be regarded as diphtheritic 
until the contrary has been proved. The laryngitis with croupy 
cough and breathing often complicating measles is not, as a rule, 
diphtheritic. 

Prognosis. — The prognosis and mortality vary with the age of the 
patient, the form and severity of the infection, and the extent to 
which organs other than the fauces and larynx are involved. Young 
infants, unless they come under observation early, give a high mor- 
tality rate. Septic forms of diphtheria are more fatal than those in 
which the process is a distinctly local affection. The mortality also 
varies with the nature of the epidemic. In Baginsky's statistics of 
2711 cases, the mortality from the sixth to the twelfth month was 52 
per cent. ; from the second to the third year, 37 per cent., decreasing 
to 8 per cent, in the tenth year. The death-rate is high in infants 
and children of delicate constitution and in those suffering from any 
form of dyscrasia. 

Treatment. — The treatment of diphtheria may be prophylactic, 
constitutional, and local. 

Prophylaxis. — The patient should be isolated as soon as the mem- 
branous deposit is detected. Other children of the family who have 
been in contact with the patient should at once be given immunizing 
doses of antitoxin, and the furniture of the sick-room, such as hang- 
ings and carpets, should be removed, only the most necessary articles 
being retained. The room should be well ventilated. The nurse 
should not come in contact with other members of the family. All 
articles of clothing worn by the patient should be dipped in an anti- 
septic solution (corrosive sublimate, 1:2000) before removal from 



DIPHTHERIA. 397 

the sick-room. The physician, before entering the sick-room, should 
cover his head with a cap and wear a long coat or bath-robe, which 
should be hung outside the sick-room. If it is necessary for members 
of the family to enter the room, they should observe the same precau- 
tions, and on leaving the room they should gargle or rinse the mouth 
with some mild cleansing solution, preferably of boric acid. A throat 
culture should at once be made. The swab should be rubbed over 
the tonsils if they are the seat of exudate ; if the case is laryngeal, 
the swab is passed over the epiglottis and posterior pharyngeal wall. 
Utensils used in feeding the patient should not be used by others. 

The patient after convalescence should not mingle with other 
children until culture has proved the absence of the Bacillus diph- 
therias from the throat. 

Constitutional Treatment. — Constitutional treatment consists first 
in the administration of diphtheria antitoxin. It is not within the 
scope of this work to enter into the details of the theory of action of 
this agent, which is the outcome of the modern experimental method 
of the investigation of disease. Its place in the therapy of diphtheria 
is now assured. The mortality of diphtheria has been greatly reduced 
since its introduction. Baginsky gives the following figures, show- 
ing the mortality before and after the introduction of antitoxin : 

Age. Before. After. 

Two years 60.2 per cent.; 25.8 per cent. 

Two to four years 51.2 " ; 17.1 " 

Eight to ten years 28.8 " ; 10 " 

Of 5794 cases in private practice collected by the American 
Pediatric Society, the total mortality was only 12.3 per cent. In 
the cases injected on the first day of the disease the mortality was 
7.3 per cent. In the laryngeal form of diphtheria the results have 
been especially favorable. In 1704 cases operated and not operated 
there was a mortality of 21 per cent., of the intubated cases, 23 
to 27 per cent., as against 60 to 70 per cent, before the introduction 
of antitoxin. 

Dosage. — The dosage varies with the age of the patient, the sever- 
ity of the infection, and the duration of the case before the beginning 
of treatment. Mild forms of local membranous affections of the 
tonsils and pharynx coming under observation on the first day should 
receive doses of antitoxin as follows: Up to one year, 1000 to 1500 
units; one to two years, 2000 to 2500 units; two to rive years, 2500 
to 5000 units. If the disease has markedly progressed twenty-four 
hours after the first injection, the initial dose should be repeated. 
The severer forms of localized diphtheria with marked constitutional 
symptoms should receive initial doses half as large again or twice as 
large. Laryngeal Terms should receive proportionately large doses. 



398 TEE SPECIFIC INFECTIOUS DISEASES. 

Fully twice the above doses are given at the outset of the laryngeal 
symptoms. The American Pediatric Society recommends as an 
initial dose 1500 units for a child under two years, and 2000 units 
for one above that age. I employ 300 units for immunizing purposes 
in very young infants, and 500 units in older children. 

The immunizing power extends over a period of three weeks. It 
is best to give an initial dose of sufficient amount, so that a repeti- 
tion of the dose will not be necessary ; on the other hand, it is advis- 
able not to give an excessively large dose. The concentrated anti- 
toxins are preferable both on account of the diminished bulk and the 
infrequency with which skin- and joint-affections follow their injec- 
tion. Recently prepared antitoxin should be obtained, for it has been 
shown that this agent deteriorates with age (Abbott), and then no 
longer contains the original unit values. 

Fig. 62. 



Antitoxin syringe with asbestos packing ; can be taken apart and sterilized. 

Time of Injection. — The antitoxin should be given as early in 
the course of the disease as possible. If membrane is present, no 
time should be lost in waiting for the result of the culture test, for if 
the disease is not true bacillary diphtheria no harm can result from 
the injection, while to wait may be hazardous to the patient. 

Mode of Injection. — The syringe with asbestos packing should 
be used for making injections. Such an instrument is easily cleansed 
and boiled. I find the back just above the buttock the most con- 
venient location in which to inject. The child can be easily held if 
this site is chosen. The parts should be carefully cleansed. The 
injection is given in the same manner as a hypodermic injection. 
The parts should not be rubbed after the injection. 

Effect of Injection. — There is a slight temporary rise of tempera- 
ture following the injection. It is thought to be due to the entrance 
into the blood of the additional toxin contained in the antitoxin. 



DIPHTHERIA. 399 

This rise is succeeded by a gradual or critical fall, which continues 
until the temperature is subnormal. The membrane ceases to spread 
and exfoliates. In some cases these phenomena may be delayed 
twenty-four hours. The next day the pulse drops, the prostration 
gives way to a clear sensorium and good heart action, and sometimes 
the children sit up in bed and play with toys. The glandular swell- 
ing also diminishes markedly. In laryngeal cases if there has been 
threatened stenosis, the symptoms retrograde. Fully one half retro- 
grade spontaneously. On the other hand, if the temperature persists 
high after twenty-four hours and the membrane continues to spread, 
the injection should be repeated, especially if the swelling of the 
lymph-nodes is marked and there are symptoms of septic infection. 

The effect of an injection of antitoxin on the blood is to diminish 
the number of leucocytes; just prior to the fall of temperature there 
is a critical hyperleucocytosis (Ewing, Schlessinger). Albuminuria 
continues, but this is also the case not only when no antitoxin has 
been used, but also in almost any infectious disease in which bacteria 
or their toxins circulate in the blood. 

The eruptions which occur after the injection of antitoxin are of 
interest. At the site of the injection an abscess or phlegmon may 
form. This is the result of uncleanliness in technique or is due to 
some irritating substance in the antitoxin. A brawny erythema 
which gradually disappears may appear in a day or more at the site 
of injection. The injection may be rapidly followed by a painful 
eruption on the extremities, consisting of circumscribed violet colored 
spots, closely resembling erythema nodosum. The subcutaneous tis- 
sues are swollen, the joints are painful, and in addition there may be 
elevated temperature and a cardiac murmur. Herpes labialis and 
herpes nasalis, urticaria-like general eruptions, and morbilliform or 
scarlatiniform eruptions have followed injections. These eruptions 
appear from a few days to fourteen days after the injection. 

Conjunctival injection, tachycardia, and arrhythmia may be 
present. 

The acute symptoms described above subside in most cases within 
two or three days. 

Kidney irritation may follow the injection' of large doses of anti- 
toxin. In many of the cases reported, however, the renal symptoms 
have not been due to the antitoxin alone, and the same may be said 
of the recorded cases of endocarditis following antitoxin injections. 

The introduction of antitoxin has by no means lessened the neces- 
sity of careful general management of a case by the physician. The 
temperature is controlled or modified by hydrotherapeutic procedures. 
Antipyretics of the coal-tar series should not be administered, as they 
weaken the heart. 



400 



THE SPECIFIC INFECTIOUS DISEASES. 



If signs of cardiac paralysis of the early type set in, full doses of 
the cardiac remedies — digitalis (if the pulse is rapid), strychnine, 
caffein, camphor, and whiskey — are given. Of the remedies, digi- 
talis must be used cautiously, else the pulse will be seriously depressed. 
Strychnia and caffein are the best and most available remedies. In 
the cases of cardiac irregularity it is best not to multiply drug reme- 
dies, or the stomach will be upset and the general conditions be aggra- 
vated. To a child three years of age we may give %so grain of 
strychnia every three hours ; whereas caffein is best used in the form 

















































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Septic form of tonsillar diphtheria ; both tonsils and soft palate involved with naso- 
pharynx. Persistence of temperature and recurrence of membrane after antitoxin injec- 
tions on the sixth day. Injection of additional antitoxin and critical drop of temperature 
thereafter. Recovery. Boy, six years of age. 



of the citrate, a grain to a child of three years of age at similar inter- 
vals. The child is kept recumbent and the most assimilable forms 
of food are given, such as milk, kumyss, soft eggs, raw or boiled. In 
those cases in which there is gallop rhythm or extreme restlessness, 
digitalis in combination with morphin is given. To a child three 
to five years of age, 2 minims of the tincture of digitalis may be given 
every three hours, and 1 or 2 minims of Magendie's solution by the 
mouth. The latter is repeated only when needed. In order to guard 
against cardiac weakness in the later period of the disease, a cardiac 
stimulant, such as strychnine, is given in small doses throughout the 
illness and in convalescence. The patient is not allowed to sit up 
too early should signs of cardiac irregularity appear at the outset of 



DIPHTHEBIA. 401 

convalescence. In all cases of diphtheria the utmost caution should 
be exercised in reference to the heart. 

The infant should not be nursed at the breast, lest the breast, be 
infected. The milk should be pumped off and fed to the infant with 
a bottle. If there is diarrhoea, the milk is suspended and the bowel 
irrigated. The milk should not be resumed until all danger from 
this source is past. Alcohol is given in moderate doses if the pros- 
tration, pulse, and temperature warrant it. Infants under a year 
receive half a drachm (2.0) of whiskey every three hours; infants 
more than two years of age, a drachm (4.0) at the same intervals. 
Diphtheria patients, especially those suffering from the septic form 
with constitutional symptoms, are kept recumbent. The adminis- 
tration of remedies is not forced, for struggling on the part of the 
patient may prove dangerous to the heart. During convalescence the 
whiskey may be replaced by wine. In these cases strychnine in small 
doses (grain %oo [0.0003] ) should be continued for some time. I 
advise a return to a mixed nutritious diet in all cases as soon as the 
temperature is normal; in this way the effect of the toxins on the 
tissues is counteracted as much as possible. 

Some physicians still resort to the internal administration of cor- 
rosive sublimate in doses of grain %oo (0.0006) or more, according 
to the age of the patient. It is given in the septic tonsillar and nasal 
cases, and also in the laryngeal forms of diphtheria. 

Local Treatment. — The presence of bacteria other than the diph- 
theria bacillus around the local lesions necessitates the use of local 
cleansing and disinfecting measures. In very young infants the 
nasal discharges are washed away by means of a glass syringe with 
a blunt rubber tip. The infant is laid on the side, and the nurse, 
standing behind the patient, irrigates the nostrils with normal salt 
solution at 110° F. (43.3° C), as shown in Fig. 9. A pus basin 
is held underneath the chin. Older children will struggle, but by 
suasion they may be irrigated in the sitting posture. If there is 
much resistance, it is not desirable to insist on irrigation. In irri- 
gating, the syringe should have a position parallel with the floor of 
the nasal fossae. Spraying with a mild solution of Listerine or 
Dobell's solution is possible in some children, impracticable in others. 
The lymph-nodes, if slightly enlarged, are best treated by the appli- 
cation of warm oil of hyoscyamus ; if very much swollen, the appli- 
cation of cloths wrung out in ice-cold water is of great utility. Small 
pieces of ice swallowed whole are grateful to the patient. 

Treatment of Laryngeal Diphtheria. — In cases of mild laryngeal 
diphtheria an injection of antitoxin should be given. The patient 
should be placed under a tent, and grains x (0.6) o( calomel sublimed 
every two or three hours, according to the necessities of the ease. 

26 



402 THE SPECIFIC INFECTIOUS DISEASES. 

The efficacy of the calomel vapor is increased by passing steam into 
the tent at the same time. A convenient method is to place the 
calomel in a spoon, and heat the spoon over an ordinary candle, held 
within the tent. The swelling of the larynx caused by the invasion 
of the Bacillus diphtheria? and other bacteria is quickly relieved by 
the calomel, particularly in croupy cases with little or no membrane 
visible above the larynx. A tent may be improvised and steam satu- 
rated with benzoin or thymol may also be passed into the tent. A 
croup kettle may be improvised from an ordinary teapot or one sold 
for the purpose may be employed. It is sometimes necessary to sus- 
pend the steam inhalations for an hour or longer, for the purposes of 
ventilation. The general treatment as to the heart, temperature, and 
food is the same as in the tonsillar forms of diphtheria. If signs of 
mechanical obstruction appear, intubation is indicated. 

Ixtubatiox. — To Joseph O'Dwyer, of Xew York, belongs the 
credit of having perfected intubation as a method of relieving mem- 
branous obstruction of the larynx in diphtheria. Intubation in 
America and on the continent of Europe has completely displaced 
tracheotomy as a remedy for relieving laryngeal obstruction due to 
diphtheria. 

Instruments. — Intubation tubes (Tig. 64) are of metal coated 
with rubber, though originally made of gilt metal. The tubes are 

Fig. 64. Fig. 65. 



O'Dwyer tube. Gauge for the age of the 

patient. 

graduated (Tig. 65) according to the age of the patient, and in their 
present form are the most ingeniously devised instruments ever given 
by American medicine to the world. The tubes are furnished with 
obturators, which fit into a handle, the introducer (Tig. 66). There 
is. in addition, a forceps ('Tig. 67") with small departing blades, called 
the extractor. Finally there is a gag (Fig. 68) so constructed that 
it may be introduced into the mouth and kept in position without 
obstructing the view of the operator. 

Indications. — TTe intubate when a progressive dyspncea. which 
produces sensible exhaustion, exists. O'Dwyer never tubed the 
larynx except as a dernier ressort, and did not approve of early 
tubage. If an infant or child shows marked retraction of the supra- 
sternal notch, retraction of the epigastrium, and stridor, with accom- 
panying labored breathing, we should at once proceed to tube the 
larynx. 

Mode of Operating. — The patient is wrapped in a blanket and 



Dl 'Fill LIE III A. 
Fig. 66. 



403 




O'Dwyer tube, obturator and handle. 



Fig. 67. 




The O'Dwyer extractor. 
Fig. 68. 




Gag of the O'Dwyer sot. 



404 



THE SPECIFIC INFECTIOUS DISEASES. 
Fig. 69. 













J 


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, 1 



Introduction of the tube along the index finger. 



Fig. 70. 







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Passing the tube over the epiglottis. 

Figs. 69, 70. — The operation of intubation of the larynx. Position of child, operator 

and assistant. 



DIPHTHEEIA, 



405 



Fig. 71. 




Introduction of the tube into the chink of the glottis. 



Fig. 72. 



>Ji 



;/" 



kv 



< 



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I 



v_ 



The index finger pushes the head Of the tube Into place in the larynx. 



Figs. 71, 72. — The operation of intubation of the larynx. Position of child, operator 

ami assistant. 



406 



THE SPECIFIC INFECTIOUS DISEASES. 



held upright in the arms of a nurse, so that the head of the patient 
is on a level convenient to the operator, who stands facing the patient. 
An assistant standing behind the nurse steadies the head of the patient. 
The gag is introduced by depressing the tongue and jaw with a tongue- 
depressor. The assistant steadies the gag as he holds the head tilted 
very slightly backward. The tube, threaded with a silk ligature, is 
with its introducer held firmly with the right hand. The index finger 
of the left hand is now introduced into the mouth to the root of the 
tongue and search made for the epiglottis. In young infants 1 the 

Fig. 73. 




Method of hooking forward the epiglottis in intubation. 



epiglottis is short. The finger must be introduced quite deeply, feel- 
ing the arytenoid cartilages of the larynx, and is then drawn upward 
until the epiglottis is hooked forward. The index finger now holds 
the epiglottis (Fig. 73), and in a small larynx a skilled operator can 
also feel the arytenoids (Fig. 74). The tube is now introduced in 
the median line of the mouth along the palmar surface of the index 
finger (Fig. 69), and the finger guides the tube over the epiglottis 

1 Peculiarities of the Larynx. — Thomson and Turner have shown that the infan- 
tile form of larynx differs materially from that found later in life. At birth and 
in infants and young children the epiglottis is very small and gutter-shaped. The 
glottis is guarded above by the aryteno-epiglottic folds, which are closely approxi- 
mated to each other. Toward the tenth year the epiglottis becomes much flattened, 
the aryteno-epiglottic folds become widely separated, and the larynx assumes the 
adult type. It is important to remember these points in the operation of intubation. 



DIPHTHERIA. 



407 



and into the chink of the glottis and prevents its slipping into the 
oesophagus (Fig. 70). 

The instrument should always be kept in the median line. The 
index finger holding the epiglottis should be held well to the angle of 
the mouth, so as to obtain plenty of room. No force should be used, 
else false passages will be made. If the first attempt at introduction 
does not succeed, we should not persist too long, but remove the intro- 
ducer rapidly and give the larynx a few moments to recover its action, 
and then try again. As the tube passes into the chink of the glottis 
the handle of the introducer is elevated, as in Fig. 71, causing the 
end of the instrument to lie against the base of the tongue. The tube 
is released, the introducer and obturator withdrawn, and the index 
finger gently presses the head (Fig. 72) of the tube into the larynx. 
The gag is withdrawn, and the silken thread passed over the ear of 

Fig. 74. 




v ^ 



The infantile larynx. Its development into the adult type at the age of nine years. 
1. Infant, three months of age. 2. Child, three and a half years of age. 3. Boy, nine 
years of age. Enlargement upward of the epiglottis and shaping of the arytenoid 
cartilages. (Thomson and Turner, British Medical Journal, December 1, 1900.) 



the patient and fixed back of the ear with a piece of rubber plaster. 
Some operators remove the thread after ten minutes. The advan- 
tages of leaving the thread are that, should the tube be coughed up 
in the absence of the physician, it can be recovered by the nurse. In 
extubating, it is an aid in removing the tube. 

No anaesthetic is required, and ordinary assistance only is neces- 
sary. The air passing into the bronchi is moistened in its passage 
through the natural passages. The danger that food particles may 
pass into the larynx has been exaggerated. The detachment of mem- 
brane in front of the tube is very infrequent. Should it happen, and 
the membrane not be expelled on removal of the tube, tracheotomy is 
admissible if asphyxia is imminent. It sometimes happens that the 
tube is expelled many times after introduction. It should be reintro- 
duced or a larger lube employed. 



408 THE SPECIFIC INFECTIOUS DISEASES. 

If the operator has chosen to leave the silken cord of the tube in situ, it 
should be passed through the space between the first molar and bicuspid tooth, 
to avoid its being gradually bitten through. Should it be bitten through, the 
finger is introduced into the mouth to the top of the tube and the thread with- 
drawn, while the tube is kept in the larynx with the finger. 

The tube is allowed to remain from twenty-four hours to five 
days. Since the introduction of antitoxin the tube is taken out 
much sooner than was formerly the practice. If there is marked 
improvement in two or three days, removal of the tube should be 
attempted and the effect of such a procedure on the breathing should 
be observed. 

Both in the Xew York and Boston hospitals many operators prefer 
the recumbent to the upright position in introducing the tube. The 
patient is easily intubed in bed or on the table in the prone position. 

Extubation. — The patient is placed in the same position as for 
intubation. The left index finger is passed into the mouth and search 
made for the epiglottis, the tip of the finger resting on the arytenoids. 
The extractor is passed along the palmar side of the finger and is 
guided into the opening in the tube by the tip of the finger. Extuba- 
tion is more difficult than intubation. The extractor should be regu- 
lated by means of a small screw, so that the blades do not open too 
far. This is to guard against injury to the soft parts of the larynx 
should the opening of the tube not be entered. 

Dangers. — The dangers of intubation include detachment of mem- 
brane during introduction, laceration of the parts, the formation of 
false passages, and asphyxia. The first rarely occurs unless force 
is used. The second can only occur as a result of rough and unskilled 
efforts at intubation. The third occurs only following prolonged 
efforts at introduction of the tube. Even a skilful operator may pass 
the tube into the ventricle of the larynx. Xorthrup has published a 
case in which there was a false pocket above the cords which prevented 
the entrance of the tube into the larynx. In other cases there is what 
is described by O'Dwyer as subglottic stenosis. Xorthrup thinks 
that this is due to swelling of the mucous membrane at the level of 
the cricoid cartilage. In these cases introduction of the tube is very 
difficult. The operator may be compelled to use force to push the 
tube past the stenosis or a smaller tube may be employed. While 
the tube is being worn, it may become obstructed by membrane. This 
is indicated by a return of the croupy cough, a snarling, flapping 
sound, and obstruction to expiration. 

To obviate these difficulties, O'Dwyer has had short tubes con- 
structed without a retaining flange. These tubes have a special intro- 
ducer. The largest size for the age is chosen, and the tube forced 
into the larynx. These tubes should be used only by skilled opera- 



DIPHTHERIA. 



W.) 



Fig. 75. 




tors. The tubes are allowed to remain but a short time in the larynx. 
Other complications are the formation of granulations or ulcerations 
around the lower end of the tube if it is too long, and at the cricoid 
cartilage if it is too large. The former condition is not serious ; the 
latter may destroy the cartilage. Granulations may form about the 
head of the tube. In this case tubes with built-up heads are used to 
press on the granulations, thus causing them to atrophy (Fig. 75). 

Feeding. — Feeding the patient after intro- 
duction of the tube requires care. Most infants 
will nurse with the tube in the larynx. In some 
there is considerable difficulty in swallowing. 
The patient is taken in the lap of the nurse and 
fed with the head held a little lower than the 
body. Fluids thus cannot enter the trachea and 
cause pneumonia. 

Treatment of the Complications Bronchopneu- 
monia. — The treatment of the bronchopneumonia 
which complicates diphtheria is similar to that 
employed in the treatment of a primary affection. 
The question of the further administration of 
antitoxin always rises in these cases. I give it 
in full doses, since it is known that the Bacillus 
diphtheria is the causative factor. 

Gastro- enteritis. — The gastro-enteritis which 
complicates diphtheria it apt to prove very serious. 
the same treatment as a primary gastro-enteritis. 

Diphtheria of the Vulva. — Both the severe and the mild cases of 
diphtheria of the vulva or of the vulva and vagina should be treated 
with antitoxin. In some of the mild forms of undoubted bacillary 
origin which I have seen, the membrane was easily removable. In 
these cases, contrary to the practice in the tonsillar cases, I remove 
the membrane with a spud wrapped with cotton. The bleeding sur- 
face left after removal is painted with a 10 per cent, solution of silver 
nitrate once daily. I have cured cases by this method alone. If 
there are extensive swelling, necrosis, and gangrene, this method will 
be of no avail, and antitoxin should be given in full doses, and re- 
peated according to indications. 

Paralyses. — The treatment of diphtheritic and especially post- 
diphtheritic paralyses is at present largely empirical. The symptoms 
appear with the degenerations in full progress. Of all the remedies 
recommended, Fowler's solution in tonic doses has seemed to give 
the best results. I have seen patients recover when given arsenic, 
nutritious food, and abundant fresh air. Hypodermic injections 
of strychnine are of questionable value. Electricity is of value as 



n i 

Built-up tubes. 

It should receive 



410 THE SPECIFIC INFECTIOUS DISEASES. 

an adjuvant to massage of the muscles only in general paralysis. It 
is questionable whether in some cases it is not capable of doing great 
harm by tiring nerve and muscle. I find that patients do very well 
with hydrotherapy and massage. In these cases the last reaction to 
reappear is the patellar reflex. 

Diphtheroid (Pseudo diphtherial False Diphtheria). — The term 
diphtheroid includes all pseudomembranous formations not caused by 
the Klebs-Loffler bacillus. It was first proposed in 1860 by Boussage, 
and has recently been adopted by Weigert, Escherich, Heubner, and 
Behring. 

Occurrence. — This form of pseudomembranous formation is most 
frequently met with in the exanthemata, especially scarlet fever and 
measles. In the former it is a common complication. It is also 
met in other conditions, and fevers such as typhoid, and may occur as 
a primary affection. 

Etiology. — The cases met in the exanthemata were first described 
by Prudden, who believed that the process was due to a streptococcus, 
the Streptococcus diphtheria?. Since then, the occurrence of the 
streptococci has been confirmed, but there have also been added to 
this group of pseudomembranous inflammations cases in which the 
pseudomembrane is caused by a diplococcus, the so-called Roux coccus. 
The pneumococcus ( Jaccoud and Menetrier) may also cause a pseu- 
domembranous angina. The Bacterium coli and the gonococcus (the 
latter in newly born infants) may cause a membranous formation in 
the mouth and throat. The Staphylococcus pyogenes aureus is also 
found in these diphtheroid membranes. 

By far the most important group is that first mentioned, the pseu- 
domembranous or diphtheroid inflammation caused by the Strepto- 
coccus pyogenes, which is none other than that isolated by Prudden. 
These cases are characterized by their favorable course; while the 
mortality in diphtheria varies from 20 to 35 per cent., according to 
the age of the patient, the virulence of the epidemic, and the early 
administration of antitoxin, the mortality of the diphtheroid cases 
ranges from 3 to 5 per cent. (Park, Baginsky). 

Symptoms and Course. — The pseudomembrane occurs on the ton- 
sils, pharynx, and larynx. There are adenopathy and fever. The 
prostration and constitutional disturbance are much less than in true 
diphtheria. Membranes and casts of the larynx and trachea may be 
expelled. Suppuration of the lymph-nodes may also occur. In many 
of these cases there is a complicating bronchopneumonia of the strep- 
tococcus type (Prudden and Northrup), which usually results fatally. 

Diagnosis. — It is not possible to make a diagnosis of diphtheroid 
from the gross appearance of the membrane. The culture-test is the 
only reliable method of determining the nature of a pseudomembra- 



SCROFULA OB SCROFULOSIS. 41 J 

nous exudate. If the first culture gives a negative result, a second 
one should be made. 

Treatment. — Clinically the treatment is much the same as in true 
diphtheria. The administration of antitoxin should not be delayed 
until the nature of the exudate is determined. It is then discon- 
tinued. An exception to this rule may be made in the scarlatinal 
form of diphtheroid, in which it is safe to wait for the result of the 
culture-test, unless it is known that the patient has been exposed to 
diphtheritic infection. In such a case antitoxin should be adminis- 
tered. In laryngeal obstruction the indications for treatment are the 
same as in true diphtheria. 

SCROFULA OR SCROFULOSIS. 

The tendency in some quarters is to ignore the existence of scrofu- 
losis as a clinical entity and to rank all these and allied conditions 
under the rubric of general tuberculosis. Bayle and Laennec first 
described this condition. 

Definition. — Scrofula is a form of infantile tuberculosis engrafted 
on a lymphatic constitution, manifesting itself in superficial catarrh 
and infections of the skin, enlargement of the lymph-nodes, and 
inflammations of the joints and bones. 

Forms. — There the two forms of scrofulosis : 

a. The tuberculous form, which is practically identical with 
cutaneous, lymphatic, and bone tuberculosis. 

b. The mixed form, in which both the tubercle bacillus and the 
pyogenic bacteria are found in the lesions and products of inflam- 
mation. 

The second form may not show the effects to as great an extent 
as the first form of the so-called tuberculo-toxic action of the toxins 
of the tubercle bacillus on the skin, mucous membranes and lymph- 
nodes. 

Occurrence. — Scrofulosis is almost exclusively a disease of child- 
hood and youth, and is rarely seen after the twentieth year. Henoch 
and Bireh-Hirschfold state that the majority of cases occur between 
the third and the fifteenth year. Females are more frequently 
affected than males. Ruhl found it to be most common between the 
sixth and the tenth year. 

Etiology.— In considering the etiology of scrofulosis, it should be 
borne in mind that at the period of life during which the disease 
occurs the lymph-nodes are not structurally fully developed. On 
account of this condition and o( deficiencies of other tissues such as 
the skin and mucous membranes, bacteria obtain easy access through 
the skin, mucous membranes, and lymph-vessels even when there is 
no breach of continuity of surface (Cornet). 



412 THE SPECIFIC INFECTIOUS DISEASES. 

It is also true that certain individuals, especially those of a 
lymphatic tendency once infected, show a predisposition to affections 
of the mucous membranes and other tissues. 

The essential causes of scrof ulosis are the tubercle bacillus and the 
pyogenic bacteria just mentioned. These bacteria are present in 
ill-ventilated rooms occupied by phthisical patients. Scrofulous in- 
fection may be traced to parents, brothers, sisters, nurses, and play- 
mates. Dried sputum is a prolific source of infection. Infection is 
favored by any solution of continuity of the skin or mucous mem- 
branes, and also by hypersemia or oedema of these tissues. 

The predisposing factors are social conditions, unhygienic sur- 
roundings, moist dark dwellings, uncleanliness, improper or insuffi- 
cient food, and lack of fresh air and exercise. The overcrowding in 
the poorer quarters of cities affords abundant opportunities for infec- 
tion. Any weakening of the system by infectious diseases, such as 
measles, pertussis, scarlet fever, diphtheria, rachitis, struma, cretin- 
ism, and erysipelas, may be the starting-point for infection. Trau- 
matism or frostbite favors the entrance of bacteria. 

Morbid Anatomy. — The mucous membranes are the seat of hyper- 
semia and thickening. There are increased secretion and activity of 
the glands, also desquamation of epithelium, and excretion of serum 
and blood-elements from the surface of the membrane. Adenoids, 
enlarged tonsils, bronchitis, intestinal and vaginal catarrh, are the 
most common of the lesions of the mucous membrane. 

Skin. — There are eczema, thickening of the epidermis, and trans- 
udation of serum and elements of the blood (erythrocytes and leuco- 
cytes). Ecthymatous eruptions are common. There may be lupus. 

Cornea. — The cornea shows conjunctivitis and phlyctenula?. 

Lymph-nodes. — The lymph-nodes show hyperplasia, which is 
scarcely noticeable in the early stages. They subsequently enlarge 
to form tumor masses, which may soften as a result of suppuration 
or may retrograde to the normal. 

The nodes in almost any part of the body may be involved. They 
are enlarged to a greater or less degree, and are infiltrated with 
tubercle. On section they show either simple caseation or mixed 
infection. The latter is the case if pyogenic infection is combined 
with the tuberculous form, ^Nodes which are the seat of cheesy 
degeneration may soften and break down, forming cold abscesses. 
These may open externally 01 into the bronchi, bloodvessels, pericar- 
dium, or peritoneum. 

Joints and Bones. — In the bones the tuberculous invasion gives 
rise to fungus or dry caries. Several such foci may be present in 
the same bone. These foci may heal and years afterward become 
inflamed as a result of traumatism or infectious disease. 



SCROFULA OB SCBOFULOSIS. 4L3 

The fingers, toes, and extremities of the long bones are thickened 
as the result of periosteal inflammation. The ends of the hones are 
the seat of tuberculous osteomyelitis. The joints may be involved. 
At first there is serous exudate without perforation into the joint 
of the tuberculous foci. Later there are thickening of the synovial 
membranes and seropurulent exudate into the joint-cavity, with 
destruction of the cartilages and heads of the bones. 

Symptoms. — General Clinical Picture. — The patient is anaemic, 
but not necessarily emaciated; on the contrary, there is a very good 
panniculus of fat in the majority of cases. The face of some of these 
subjects presents an eczematous or lupoid eruption. The lips are 
thick; the conjunctivae may be injected, and there may be blepharitis 
or phlyctenula of the cornea. Snuffles and nasal catarrh or ozsena 
are present. The majority of the patients are mouth-breathers, and 
suffer from adenoids and enlarged tonsils. In some there is chronic 
otitis with an offensive discharge. There is a fulness about the neck 
due to enlarged lymph-nodes. The body may present skin eruptions 
in the form of ecthyma or varieties of eczema. The general surface 
is in other cases free from eruption, is pale, and has a transparent, 
marble-like appearance, showing the blue veins underneath. Many 
of these patients give a history of chronic bronchitis. In others the 
remains of old suppurations of the lymph-nodes about the neck are 
seen in the form of livid cicatrices. If the long bones of the extremi- 
ties have been affected, the surface of the skin shows either old or 
recent bone sinuses. The symptoms in most cases develop first on 
the skin and mucous membranes; the lymph-nodes then enlarge, the 
bones and joints are next involved, and finally, if the case does not 
progress favorably, amyloid degeneration of the different organs and 
emaciation develop as a result of prolonged suppuration. In all 
cases the changes in the lymph-nodes play a leading part, and are 
characteristic. 

The Shin, — In the unmixed tuberculous form lupus is the most 
common skin lesion; in another form there is the so-called scrofu- 
loderma of Besnier. Lichen scrofulosorum, with the characteristic 
enlargement of the lymph-nodes, is another form of skin eruption. 
In the second form eczematous and acneform eruptions are present. 
In such cases the skin is thickened as a result of chronic inflamma- 
tions. There are suppurating rhagades around the eyes, mouth, and 
anus, and ecthymatous eruptions may be present on the trunk and 
extremities. A form of scrofulous ecthyma, made up of purple, 
painful nodules resembling erythema nodosum, has been described 
by Hutchinson. Hebra has described a prurigo of the scrofulous 
subject. 

Mucous Membranes. There are ulcerations and chronic catarrh 



414 THE SPECIFIC IXFECIIOUS DISEASES. 

of the nasal and bronchial mucous membranes, and in some cases 
ozaena of an atrophic character. These patients have adenoids and 
enlarged tonsils. The tonsils are favorite seats of infection. In 
other cases the posterior nasal and pharyngeal catarrh leads to retro- 
pharyngeal abscess, or caries of the spine may canse abscess forma- 
tions in the retropharynx. 

The Ears. — As a result of the catarrh of the nasopharynx chronic 
otitis may develop. When otitis follows any of the exanthemata in 
a patient with scrofulous tendencies, it pursues a chronic painless 
course. Such an otitis may tend to tuberculous disease of the mas- 
toid with sinus thrombosis, or even to tuberculous meningitis. There 
is pain only when there is a mixed pyogenic infection. 

The Eye. — Chronic eczema of the lids, blepharitis, phlyctenula 
of the cornea, and keratitis fasciculosa are seen. The phlyctenular 
do not yield readily to treatment. Hypopyon of the anterior chamber 
may also be present. Trachoma is in some instances of a tuberculous 
origin. Lupus of the conjunctiva is sometimes present. 

Lymph-nodes. — The tuberculous and tuberculo-pyogenic forms of 
enlargement of the lymph-nodes are at the outset similar. The pyo- 
genic varieties are associated with enlarged tonsils and adenoids. 
The skin over the enlarged nodes may remain normal for months 
or years, or in both the tuberculous and pyogenic varieties it may 
become adherent, red. inflamed; and break down. The lymph-nodes 
discharge, leaving suppurating cicatricial openings. 

Clinically, infections of the scalp lead to enlargement of the 
lymph-nodes of the neck and retromaxillary region. Those of the 
cornea, iris, and ear tend to enlarged preauricular nodes and to 
enlarged nodes of the submaxillary region. Infections of the mouth 
and tonsil cause enlarged nodes at the angle of the jaw and beneath it. 

Otitis with mastoid disease causes enlargement of the node on the 
point of the mastoid. The lymphatics of the gums and lips are con- 
nected with the nodes of the submaxillary region and angle of the 
jaw. Affections of the nose will cause enlargement of the glands of 
the neck (Jacobi). Lesions of the fingers will result in enlargement 
of the cubital and axillary nodes. Infection of a circumcision wound 
or balanitis will cause enlargement of the inguinal lymph-nodes, as 
will also infections of the foot and knee. 

The lymph-nodes in direct line are always involved ; distant ones 
are never infected unless there is infection of the intermediate nodes. 
It was formerly believed that the bronchial nodes were particularly 
subject to infection. Any special susceptibility to infection shown 
by these nodes is due to their location, infectious material being fre- 
quently present in their vicinity. 

Cornet found the bronchial nodes affected in 103 out of 126 cases 



SCliOFULA OB SCBOFULOSIS. 



415 



of tuberculous disease occurring before the completion of the fifteenth 
year. These observations confirm the statement of Henoch, that the 
bronchial nodes are affected in the majority of cases of tuberculous 
disease. Becker, Barthez and Billiet, Henoch, and ISTorthrup have 
described the enlargement of bronchial nodes. According to Henoch, 
they may, even if tuberculous, be enlarged without involving the lung 
tissue. By pressing on the vagi they may cause rapidity of pulse, 
and if on the recurrent laryngeal may give rise to spasmodic dyspnoea 
or to a croupy cough. Pressure on the oesophagus may cause dys- 
phagia ; pressure on the trachea may cause inspiratory dyspnoea ; and 
pressure on the pulmonary veins, hypersemia of the lungs. Henoch 
and Baginsky doubt the possibility of diagnosing these enlarged nodes 
even with the help of all these symptoms. 

Fig. 76. 




Tuberculosis of the proximal phalanx of the index finger in a scrofulous child the subject 
of extensive lupus of the face and extremities (" Spina ventosa "). 



These nodes may retrograde to the normal size (West) or they 
may break down and perforate into a bronchus or the trachea. If 
they perforate into the pericardium, pleura, or mediastinum, inflam- 
mation results at these points. 

The mesenteric lymph-nodes may enlarge and cause pain or tuber- 
culous infection of the peritoneum (tabes meseraica). In some cases 
they may be palpated through the abdominal wall. 

Bones and Joints. — The extremities of the long bones are most 
frequently the seat of disease ; the diaphysis rarely so. The phalanges 
of the fingers, the toes, the radius, the ulna, and fibula, are affeeted 
in the order of naming. The joint-cavities may at firsl contain 
exudate without perforation of the cartilage; later, pus is found in 
the cavity. 



416 TEE SPECIFIC INFECTIOUS DISEASES. 

All of the structures of the joint are involved, and the joint may 
eventually be destroyed. Suppuration of a chronic nature may, as 
stated elsewhere, tend to amyloid degeneration of the liver and spleen. 

There is, in addition, a progressive anaemia. The temperature 
is sometimes raised a half or three-quarters of a degree above the 
normal, at others it is normal. Exhausting sweats occur; the dis- 
turbances of nutrition become in some cases extreme. There may be 
intestinal diarrhoea. 

Course and Prognosis. — This condition is not necessarily fatal. 
Many cases make a good recovery under proper management. The 
disease may retrograde if localized to certain lymph-nodes or bone foci. 

Diagnosis. — The diagnosis is made from the clinical history; 
either from the presence of the tubercle bacillus in the pus or lesions 
of the disease, or in those forms in which it is not always possible 
to decide whether the process is tuberculous or pyogenic by the pres- 
ence of the tuberculin reaction. Most striking is the cutaneous tuber- 
culin reaction in cases in which there is a so-called tuberculo-toxic 
effect on the tissues. Here we have latent tuberculous foci out of 
reach of observation. The tuberculous toxins permeate the tissues 
and as a result the " allergie " reaction of Von Pirquet is very marked ; 
more so than in cases in which there are open foci and tubercle bacilli 
can be demonstrated. The reaction is large, fully 10 cm. in diam- 
eter and may develop to necrotic ulcers. The clinical history and 
blood examination will be of service in differentiating scrofulosis 
from leukaemia, pseudoleukaemia, and lymphomata of a malignant 
nature and late forms of hereditary syphilis. 

Treatment. — The treatment of scrofulosis is directed toward lim- 
iting if possible the spread of the infection, preventing reinfection 
of the patient, and instituting local treatment of the lesion. In order 
that the disease may be treated successfully, the patient should be 
placed in good hygienic surroundings. If the patient is in the city, 
removal to the country is advisable. The food should be plain and 
nutritious; milk, eggs, meat, vegetables, and cereals should form the 
diet. The hygiene of the skin is important. Alkaline or sea baths 
give tone to the skin. Moderate exercise in the open air is also of 
great service in correcting the anaemia and tendency to inaction shown 
by these patients. In a word, the patient should be removed from the 
conditions and surroundings which originally induced the infection. 

The medical treatment is limited to the exhibition of such tonics 
as iron, Fowler's solution, and strychnine. The intestines should 
receive attention during the administration of iron. Fowler's solu- 
tion gives better results in pyogenic lymphadenitis than in the tuber- 
culous form. The syrup of ferric iodide in full doses has a tonic 
effect on the mucous membranes. Baginsky advises the exhibition 



TUBEBCULOSIS. 417 

of preparations of thyroid gland. I have not seen any markedly 
good results obtained by this method of treatment. 

Cod-liver oil is of great value in this disease. In the form of 
emulsions it should be given in full doses; with young children its 
use must sometime s be suspended on account of the laxative effect on 
the intestines. The tuberculin treatment by very small hypodermic 
injections of Koch's old tuberculin (%oooo of a milligram at a dose) 
causes a remarkable improvement in these cases. The complete 
restoration is indicated by an absence of the cutaneous tuberculin 
reaction. 

The local skin lesions should receive appropriate treatment, as 
should also the bones, joints, and suppurating lymph-nodes. It is 
not within the province of this work to enter upon the surgical details 
of such treatment. 

TUBERCULOSIS. 

Definition. — Tuberculosis is a specific infectious disease caused by 
the invasion of the body by the tubercle bacillus. 

Clinical Varieties. — The tuberculous infection in children may be 
general or local. 

If general, tuberculosis may manifest itself as a primary infec- 
tion without demonstrable port of entry or it may be secondary to a 
well-marked primary focus of infection. 

If local the tuberculosis may remain localized at the primary focus 
of infection or may extend from an evident port of entry by con- 
tinuity but remain localized. 

Clinically it is not always possible to fix on the primary source 
of infection, but postmortem we can judge which focus was primary 
and which secondary, especially in tuberculosis, on account of the 
anatomical changes in the retrogressive lesions such as cicatrization, 
calcification and encapsulation. Thus during life what appears as a 
pulmonary tuberculous lesion may postmortem reveal itself as sec- 
ondary to some partially cicatrized ulcer of the intestine or a calcified 
mesenteric lymph-node. Moreover, all forms of tuberculosis can not 
be definitely classed as above. There are especially in children mixed 
forms. All tuberculosis is not fatal and a great many of those 
affected with tuberculosis may never have shown any clinical symp- 
toms. In these cases of healed tuberculosis the lesion is revealed by 
-omo intercurrent affection or accidental death. 

Frequency of Tuberculosis in Childhood.. — Kossel in 286 autopsies 

found that the frequency in the firsl year o( life was 6 per cent.. 

Prom the first to the fifth year 8 per cent., and from the first to the 

tenth year r 'H'> per cent. The frequency o( tuberculosis in children 

27 



418 



TEE SPECIFIC INFECTIOUS DISEASES. 



varies in different localities. Thus in 600 autopsies in children, 
Dennig found 7 per cent, tuberculous; Bollinger, 13.6 per cent, in 
500 autopsies; Seidl, 27.9 per cent, in 64:6 autopsies, and Raczynoki, 
18.3 per cent, in 3341 autopsies. 

From a study of all tables of various authors we may say that in 
one hundred autopsies on children 29 or 30 either died of tuberculosis 
or that it was found as a concomitant with the fatal lesion. Tuber- 
culosis under the age of three months is rare and only occasional up 
to the twelfth month of life. The frequency then rapidly increases 
up to the sixth year of childhood, after which it decreases. During 
the first four weeks of infancy Trepinski found no deaths from tuber- 
culosis, from the fifth to the ninth week one case which may have 
been intra-uterine, and from the third month of infancy to the third 
year of childhood a gradually increasing ratio until the fifth year, 
when a decrease was noted. In short, in the first five years of child- 
hood tuberculosis is found in fully 50 per cent, of autopsies. 



Localization of the Lesion in Tuberculous Children. 





Lungs. 1 Bronchial 




Mesenteric 


Primary In- 
testinal T. 


Peri- 


Lymph 




B Nodes. 




Nodes. 


toneum. 


Nodes. 




1 




10.6 








Bovaird 


80% 
66% 




Carr 


16.6 




Dennig 


14.7 


21.3 


1 








Grosser 








0.052 














t j 




Holt 


34.0 




Northrup 


70% 


2.5 








Still 


72% 


23.4 








Trepinski 


90.4 


70.8 


17.4 


20.8 




17.9 


75.8 


Kossel 




40 
Including 
mesen- 
teric 
glands. 




9 


4.5 




51 



Pathogenesis. Portals of Entry and Modes of Spread. — The tuber- 
culous infection may be aerogenous (inhalation), enterogenous or 
alimentary (inclusive of amygdalogenous), lymphogenous or hsema- 
togenous, dermogenous (through the skin), and finally hereditary or 
congenital. 

. Aerogenous Form. — This form of infection, that by inhalation, 
by far the most frequent form in the adult, is also the commonest 
type in children. Dennig found that 58 per cent, of his cases of 
tuberculosis occurred in families in whom tuberculosis was prevalent. 
That inhalation tuberculous infection is by far the most natural form 
of infection in children is proven by Lubarsch, who in 1820 autopsies 
found tuberculosis of the lungs, and bronchial lymph-nodes in 80 to 



TUBERCULOSIS. 419 

96 per cent, of the cases. Tubercle bacilli which are inhaled may 
give rise to intestinal or enterogenous or alimentary infection by 
gaining access to the alimentary tract, leaving the lungs intact. 

Enterogenous or Alimentary Form. — This variety in children 
takes an especial rank of interest on account of the possibility of 
infection through the milk of infected cows. This question has been 
discussed at interminable length and an attempt has been made to 
reconcile the varying statistics in different countries. In England 
it is considered a rather frequent form of infection. Still attributes 
25 per cent, of his cases to it. Alimentary infection may result not 
only from the ingestion of food containing tubercle bacilli but also by 
the accidental entrance of bacilli into the mouth and thence into the 
alimentary tract. From a study of all aspects of this question it 
would appear that this form of infection undoubtedly occurs but is 
exceedingly rare. 

Tuberculosis of the tonsils which is included under the general 
section of alimentary form of infection is also exceedingly rare. I 
have published a case of primary infection of the tonsils leading to 
general tuberculous infection. 

H cematogenous or Lymphogenous Form. — This type is never pri- 
mary but occurs through the breaking down of some tuberculous focus, 
the opening up of a bloodvessel or lymph-channel and the spreading 
thus of tuberculous material through the circulation. 

Dermogenous Form. — This form is seen in those cases of tuber- 
culous cutaneous disease in persons whose occupation brings them 
into close contact with tuberculous tissues or animals. Such are the 
autopsy tubercles and the cutaneous tuberculosis seen among butchers 
who have handled tuberculous meat. It is therefore scarcely to be 
considered a form of infection in children. 

Predisposing Causes. — The infectious diseases play an important 
role as predisposing factors in tuberculosis. Measles, scarlet fever, 
pertussis, and influenza, by lessening the resistance of the economy 
and impairing the integrity of the air-passages, favor the infection. 
Tuberculous bronchopneumonia occurs under these conditions, either 
because the tubercle bacillus was present in the body before the infec- 
tion was contracted or gained access subsequently (Framkel). In 
the majority of cases the former condition is the rule. Cold, un- 
hygienic surroundings, and poor food, all predispose to infection as 
with adults. 

Congenital or Foetal Tuberculosis. — Fatal infection may take 
place either through an infected sperma or ovum (germinative), 
through the placenta (intra-uterine), or it may be pseudo-congenital, 
that is, occur very shortly after birth. The last form has caused much 
discussion, especially in eases of tuberculosis in which the infant dies 



420 TEE SPECIFIC INFECTIOUS DISEASES. 

of tuberculosis some weeks after birth. It is then an open question 
as to whether the infection was intra-uterine or post-partum. There 
are six cases of undoubted foetal tuberculosis in the literature ( Jacobi, 
Birsch Hirschfeld, Lehman, Schmorl, Kockel and Wollstein). 

Of the cases occurring in very early infancy and the newborn, 
very few exist in the literature which may be traced to intra-uterine 
infection, and are therefore to be considered as congenital. In these 
cases the children died so soon after birth, and the lesions were so far 
advanced, as to justify this assumption. Tubercle bacilli are exceed- 
ingly rare in the testis or sperma, and it is questionable whether in 
such cases a tuberculous foetus can result. In the human subject 
there is not one authentic example of infection through the sperma 
of a tuberculous individual. Among animals we find that there are 
many cases of observed intra-uterine infection ; but no cases in the 
human subj ect of infection brought about by insemination of the male. 

The spermatozoon and testis may contain tubercle bacilli in the 
absence of gross tuberculous lesions of the organ (Nakarai and 
Kockel). Tuberculosis may in this way be conveyed into the uterus 
at the time of conception. Jahni and Weigert found tubercle bacilli 
also in the Fallopian tubes of women dying of phthisis, although 
there were no gross changes in the tubes. The ovum may thus convey 
tubercle bacilli. True congenital tuberculosis, therefore, in the sense 
just intimated, is rare. Foetal tuberculosis occurs, as shown above, 
but is not such an important mode of infection for so widespread a 
disease as tuberculosis. 

There is another form of foetal tuberculosis, and that is the so- 
called bacillosis or bacillary form. In this form the foetus is found 
to be free from the lesions of tuberculosis, but bacilli are found in the 
umbilical vein or in the liver or in the foetal organs. Such are the 
cases, including that of Bngge, of foetal tuberculosis without lesions. 
The rarity of the tuberculosis of the foetus is due to the fact that 
bacillosis of the mother is rare. Bacilli occurring free in the circu- 
lation in advanced phthisis is rare in itself; and they soon become 
localized in the tissues. The placenta, as also the liver of the foetus, 
acts as a barrier and filter of the tubercle bacilli, or they die in the 
blood-stream. 

The characteristics of foetal tubercle are: (1) That it is rarely 
pulmonary. The liver is frequently affected, also the spleen, kidneys, 
and suprarenal capsules ; whereas in the lungs only isolated tubercles 
are found. (2) Foetal tissues are a favorable soil for tubercle. (3) 
Giant cells are wanting. (4) Bacilli may be present in large num- 
bers without the development of gross lesions (bacillosis without 
lesions). 

Under placental infection are to be included those cases in which 



TUBERCULOSIS. 421 

the tubercle bacillus has been found in the blood of the foetus without 
accompanying changes in the organs (Schmorl), and those in which 
tubercle nodules and enlarged lymph-nodes have been found at birth 
(Landouzy and Lehman). In both these forms of tuberculous infec- 
tion the mother had suffered from acute miliary tuberculosis. 

Pulmonary Tuberculosis. — Seventy per cent, of the infants and 
children who die from tuberculosis show lung-changes (Dennig). 
Infection first occurs through the respiratory tract. A cheesy lymph- 
node may burst into the bronchi, and bacilli may thus gain access to 
the lung alveoli and cause changes, as they do in the adult lung. 
Hematogenous infection occurs through the bursting of a small tuber- 
culous nodule into a bloodvessel, thus flooding the lung with infec- 
tious matter, or by the carrying of minute emboli of this material to 
distant parts of the lung. 

Tuberculous bronchial lymph-nodes, bone, and pleura may also 
give rise to infection of the lung through the lymph-channels. The 
part played by the infectious diseases in its dissemination has been 
already mentioned. 

Morbid Anatomy. — The three principal forms of tuberculosis of 
the lungs which occur in infants and children are : 

Miliary Form. — The miliary form, which is characterized by the 
eruption of miliary tubercles throughout the lung. The lung is on 
section found to be dark red, hypersemic, and to contain less air than 
the normal lung. The bronchial mucous membrane is hypersemic 
and covered with blood and mucus. 

Cheesy or Cheesy Ulcerative Form. — The cheesy or cheesy ulcera- 
tive form, also called florid phthisis, takes the form of cheesy lobar or 
lobular pneumonia. In recent cases the lung is grayish red, and 
there are areas which rapidly become cheesy, and are not encapsu- 
lated. These may coalesce, involving the greater part of a lobe in 
the process. Small cavities are frequent, large ones rare. The 
cheesy ulcerative form occurs as a result of the aspiration of large 
numbers of tubercle bacilli. 

Chronic Form,. — The chronic form, which is a cheesy fibrous 
bronchopneumonia, is essentially a tuberculous bronchopneumonia. 
Kound cheesy nodules are found surrounded by a fibrocellular zone 
resulting from the destruction of extensive areas of lung-tissue. The 
pulmonary pleura is thickened. The bloodvessels participate in the 
process. There is endarteritis with miliary tubercle in the walls of 
the bloodvessels, and there may be thrombosis. The tubercles may 
burst into the interior o( the bloodvessels. The bronchi, trachea, and 
larynx. may be affected. There are ulcerations of the mucous mem- 
brane and destruction o( cartilage. The bronchial lymph-nodes or 
glands are enlarged and infected in most cases o( tuberculosis of the 



422 THE SPECIFIC INFECTIOUS DISEASES. 

lungs in children. Henoch has, however, shown that the bronchial 
nodes may be tuberculous and greatly enlarged without involvement 
of the lung-tissues. Xorthrup found the bronchial lymph-nodes 
affected in 125 consecutive autopsies. The whole node is converted 
into a cheesy mass, which may soften and break down. If there is a 
perforation into a bronchus, masses of bacilli may be discharged into 
the lung. Perforation into the bloodvessels may also occur. The 
nodes may form small masses or large mediastinal tumors at the root 
of the lung. 

Localization. — The apices of the lungs of infants and children are 
not as in adults the region most frequently affected by tuberculosis. 
The first change may appear in the lower lobe or the lower portion 
of the upper lobe, and spread thence. This is accounted for by the 
miliary character of the affection in the lungs of infants and children 
(Rindfleisch), and also by the fact that in many cases the process 
spreads from the bronchial nodes or glands to adjacent parts ( Weigert) . 

Symptoms. — The symptoms of tuberculosis of the lungs in infants 
and young children are not so characteristic as in the adult, nor is 
there a gradual development of the symptoms pointing to involvement 
of the lungs. After the fifth year of life the symptoms closely resem- 
ble those seen in the adult. As regards infants, we shall describe 
only clinical types of the disease. Even these exhibit many varieties. 

Henoch has described forms of tuberculosis in infants which 
closely resemble cases of marasmus due to gastro-enteric disease. In 
many of them there are steady emaciation and progressive muscular 
weakness; the infant lies helpless; the abdomen is retracted; the 
eyes may present a conjunctivitis; the cervical, axillary, and inguinal 
glands may be slightly enlarged; there is constipation alternating 
with diarrhoea ; the skin is easily inflamed and abscesses may form. 
In the terminal period vomiting sets in. The lungs throughout the 
course of the disease may present few signs, or there may be evidences 
of a general bronchitis. In these slowly emaciating infants there is 
no cough of sufficient severity to indicate involvement of the lung. 
The terminal stage may present cerebral symptoms of a mild type, 
such as rigidity of the neck, with periods of stupidity alternating 
with irritability. The infants die with a progressive loss of flesh 
and strength. The temperature is for days normal or a little above 
normal. In other types the disease is masked by an acute or sub- 
acute bronchopneumonia. In these cases the infant, after suffering 
from exposure or some infectious disease, suddenly exhibits all the 
signs of a bronchopneumonia. There are severe cough, high tem- 
perature, dyspnoea, and cyanosis, as in the ordinary bronchopneu- 
monia. Death may ensue in a few days or in a week. In other 
forms fatal results take place after several weeks, with symptoms 



TUBERCULOSIS. 423 

closely resembling those of a persistent bronchopneumonia of the 
ordinary non-tuberculous variety. 

In other cases the symptoms of an acute bronchopneumonia are 
present, sometimes complicated with empyema. Evacuation of the 
pus is followed by apparent improvement, and the empyema may even 
heal, but the infant or child gradually emaciates, and the cough, 
which may have abated, becomes aggravated. Examination of the 
chest reveals new areas of lung involvement. In these cases the pus 
does not always contain the tubercle bacilli. The empyema may be 
the result of mixed infection, and the pus may contain only simple 
streptococci, the physician being frequently misled as to the true con- 
dition. Many forms of tuberculosis of the lungs in infants and 
children may cause death with the terminal symptoms of tuberculous 
meningitis. 

Especially characteristic in older children, as compared with the 
adult, are those cases of tuberculosis of the lung which follow some 
slight injury, blow, or exposure, and in which there are for weeks 
no signs in the lung or elsewhere to account for the gradual emacia- 
tion and intermittent or remittent temperature. After a variable 
length of time signs of involvement are detected at one apex, or 
posteriorly over the base or mid-area of the lung. Even then the 
cough may be absent and no sputum be expectorated. The child then 
has intervals of stupidity; there is delirium at night accompanied 
by the typical hydrocephalic cry. Irritability of temper is marked, 
the emaciation is very rapid, and coma and death with terminal paral- 
yses show that the infection has involved the cerebral meninges. 

Temperature. — The temperature is irregular in course. It may 
be normal for a few days, after which it rises one or two degrees 
daily in the afternoon and falls to the normal toward morning. 

Hcemoptysis. — Haemoptysis is very rare in infants. Henoch 
has seen 3 cases in young infants and 1 in a child of two years. Acker 
has reported a case in a child of three years. I have seen several 
cases in children of more than six years of age. 

Sputum. — Infants do not expectorate. At most a frothy mucus 
collects around the orifice of the mouth after a coughing spell. Even 
older children expectorate very little, and must be taught to do so. 

Holt has recently devised a method by which tubercle bacilli may 
be obtained in sputum adherent to the epiglottis by carrying a small 
cotton swab into the fauces and catching the mucus from the epiglottis 
in the act of coughing. 

Course.' — Up to the second year of life, the course of tuberculosis 
of the lungs is generally acute (Henoch). The disease may pursue 
a subacute course, but it is rarely as prolonged as in the adult. In 



424 



TEE SPECIFIC INFECTIOUS DISEASES. 



children beyond the fifth year its course closely resembles that taken 
in the adult. 

Diagnosis. — The diagnosis of tuberculosis of the lung in infancy 
and early childhood must, for the most part, be made from the his- 
tory of the case. In many of the cases the physical signs in no way 
differ from those seen in non-tuberculous diseases. Cases in which 
marked consolidation of the lung persists, with progressive emacia- 
tion, and cases in which auscultation reveals the presence of cavities, 
are certainly suspicious. There is no reliable method of determining 
the nature of an acutely developing bronchopneumonia ; the detection 
of the tubercle bacillus in the vomit, in the fasces, or in the exudate 
of a complicating pleurisy or empyema, is of diagnostic aid. 

Fig. 77. 



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Subcutaneous injection, tuberculin negative at first and positive on the second injec- 
tion. Case of peritoneal tuberculosis. 

The existence of enlarged lymph-nodes in the mediastinum or the 
root of the lung is, according to some authors, revealed by symptoms 
of pressure. Pressure on the bronchi may give rise to dyspnoea ; on 
the large veins, to nervous congestion and cyanosis, or oedema of the 
lungs ; on the recurrent laryngeal nerves, to asthma or laryngospasm ; 
on the oesophagus to dysphagia. Although in exceptional cases such 
symptoms may be thus correctly interpreted, I believe with Henoch 
that diagnosis of these enlarged nodes during life is highly uncertain. 

Tuberculin" Test. — The tuberculin test for tuberculosis will aid 
in corroborating the diagnosis in any particular case. There are 
three well recognized tuberculin tests: The subcutaneous test, the 
conjunctival test of Calmette and Wolf-Eissner, and the cutaneous 
scarification test of von Pirquet. There is also a fourth test, the 
so-called Moro inunction test, but this is not in general use. 



PLATE XXIV 




Cutaneous Reaction with Tuberculin. Cas< 

tuberculosis in a child six years of age. 



TUBERCULOSIS. 



42o 



Fig. 78. 



Subcutaneous Test. — The subcutaneous test consists of injecting 
underneath the skin 0.1 to 0.5 of a milligram of old tuberculin Koch. 
Within 24 hours there occurs a so-called reaction or rise of tempera- 
ture to a variable extent ; after a short time the temperature again 
falls to the normal without further symptoms (Fig. 77). 

Conjunctival Test. — The conjunctival test is not generally applied 
in children on account of the untoward effects which may follow its 
application in certain cases. When a drop of tuberculin solution is 
instilled into the eye of an individual in whom 
there is tuberculous virus, there occurs in from 
four to twenty-four hours an injection of the pal- 
pebral conjunctiva, semilunar fold, caruncle and 
orbital conjunctiva, which varies in intensity in 
different individuals. It is attended by lachry- 
mation and a fibrinous or fibrino-purulent exu- 
date. This may go on to profuse suppuration 
attended by very marked swelling of the tissues of 
the orbit. This reaction reaches its maximum in 
24 to 48 hours and then gradually subsides. 

Cutaneous Scarification Test. — The cutaneous 
scarification test consists in scarifying the skin by 
means of a so-called borer. The skin of the 
left forearm on the anterior and radial aspect is 
cleansed with ether and three punctate scarifica- 
tions are made by means of the V. Pirquet (Fig. 
78). This instrument is shaped very much like 
a watchmaker's screw-driver. It is held perpen- 
dicularly to the arm and with a twisting, rotary 
motion in the manner in which the watch-maker 
screws the screw into its socket the scarifications, 
three in number, are rapidly made. Two of the 
scarifications are inoculated with a minute drop of 
old tuberculin; the third scarification is left untouched for control. 
After three or four seconds the tuberculin is wiped off the scarifica- 
tions. In from Rye to twenty-four hours there develops a pink areola 
around the scarifications inoculated with tuberculin. This areola 
ranges from Rye to ten millimetres in diameter and is somewhat infil- 
trated and papular. The extent of the areola and infiltration varies 
in different individuals. It fades after a variable length of time, 
persisting longest in scrofulous individuals or in those having abun- 
dant antibody, as it is called, in the blood (Plate XXIV.). 

This reaction of Von Pirquet is certainly clinically the nu>st 
useful of all the so-called tuberculin tests. It is never followed by 
any untoward results. It is absent in many cases before death, and 



Borer for making 
the cutaneous tuber- 
culin test. 



426 THE SPECIFIC INFECTIOUS DISEASES. 

in cases of measles in the first week of the period of Koplik spots and 
the skin exanthema. 

The principle of all the reactions has been explained by Von 
Pirquet on the theory of so-called " alle'rgie " (allergistic reaction), 
that is to say, when an individual contracts tuberculosis, there develops 
a hyper-sensitiveness of the tissue-cells to the poison of the tubercle 
bacillus ; in other words, there is an acquired immunity to the tubercle 
poison against which the system attempts to protect itself. This 
acquired immunity is developed by the creation in the blood of a 
so-called antibody or " antigone." It is sometimes necessary in the 
presence of a negative result to repeat the test. A test negative on 
the first trial may result positive on the second inoculation. These 
cases include many so-called latent cases of tuberculosis. 

Treatment. — From a study of the symptomatology it will be seen 
that the treatment of tuberculosis of the lung in young infants aud 
children must be simply symptomatic and will not differ materially 
from that of the adult. A case of suspected tuberculosis should be 
isolated from other children. The fever needs little attention if it 
remains low ; if high, it is treated as in a case of simple bronchopneu- 
monia. The cough and restlessness are also treated symptomatically. 
The feeding and general nutrition are of extreme importance as well 
as change of climate and hygienic surroundings. 

Tuberculosis of the Peritoneum (Tuberculous Peritonitis). — 
Occurrence. — According to the statistics of Dennig, Miiller, Biedert, 
and Simmonds, tuberculous peritonitis occurs in from 8 to 21 per 
cent, of all the cases of tuberculous disease. Sixty-five per cent, of 
the cases operated on by Herzfeld were under the age of fifteen years. 
The frequency varies in different localities. 

Acute tuberculosis of the peritoneum is seen in acute phthisis as 
a complication, when there may be also an exudate with miliary tuber- 
culosis of the peritoneum. This form of peritoneal tuberculosis is 
of no clinical interest. 

Chronic Form. — This is the form under consideration. It is rare 
in the newborn; in a statistic of 100 cases Still found the disease most 
frequent from the second to the fifth year of life. Next in frequency 
was the period of five to ten years. 

Etiology. — Tuberculous peritonitis is rarely if ever primary, 
although such cases have been described by Henoch and Miiller. 
The peritoneum may become infected through the blood-channels 
( hematogenous) ; under these conditions tuberculosis of the perito- 
neum is simply a feature of the manifestation of acute miliary tuber- 
culosis. The peritoneum may become infected through the lymphatics 
or lymph channels (lymphogenous). Under these conditions it is 
the result of infection from adjacent organs, such as the intestines, 



. TUBERCULOSIS. 427 

the genitourinary tract, the mesenteric, peritoneal, retroperitoneal, or 
bronchial, lymph-nodes, and the vertebrae and pleura. 

Morbid Anatomy. — There are, according to Herzfeld, three main 
forms of tuberculous peritonitis: the miliary, submiliary or exudative 
form; the nodular or sclerosing form; and the adhesive form. 

The Miliary, Submiliary, and Exudative Form. — In this form 
there is an eruption on the peritoneal surface, of gray, transparent 
tubercles of varying sizes. The intestinal coils are covered with 
fibrin, and are slightly adherent to one another. There is a clear 
serous, serofibrinous, seropurulent, or even ichorous exudate (mixed 
infection). 

The Nodular or Sclerosing Form. — In this form the quantity of 
the exudate in the abdominal cavity is small. The omentum is con- 
verted into a solid cylindrical mass, containing tumors of a tuber- 
culous nature as large as an apple. The mesentery is thickened and 
covered with tubercles. The intestinal wall is thickened and covered 
with gray or grayish-yellow tubercles, which may attain the size of 
tumors. The coils of gut are adherent, and the whole peritoneal 
cavity may be obliterated. 

The Adhesive Form. — In this form the intestines form an adher- 
ent mass, with masses of exudate between the coils of gut, forming 
pseudocysts. This exudate may be of a puriform nature. Aggre- 
gations of tubercles between the coils of gut break down and perforate 
into the gut, or become adherent to the abdominal wall and perforate 
externally, forming intestinal or abdominal fistulse. Perforation 
may thus occur in the absence of any real ulceration on the mucous 
membrane of the gut. 

In addition to the above principal forms of tuberculous perito- 
nitis, mixed forms occur. 

The exudate in the peritoneal cavity may be purely serous 
(ascites), or the serum may, as in a case which I observed, have a 
chylous appearance, due to the admixture of fat. In other forms the 
exudate may be seropurulent, hemorrhagic, or, in mixed infections, 
putrid. In the purely ascitic variety the fluid is free: in the puru- 
lent form, it is frequently sacculated between the adhesions on the 
coils of gut. 

Symptoms. — The disease is, as a rule, insidious and slow in devel- 
opment. The stage of abdominal distention has usually boon reached 
when the patient is first brought to the physician. The history shows 
that the child has been for some time gradually losing weight, thai 
the appetite is capricious, and that there have been attacks of abdom- 
inal pain. This pain may be localized or radiate from one point, 
may be constant, or may resemble viscera] neuralgia. Sometimes 
there is no history of pain, but it may be detected by pressure on 



428 



THE SPECIFIC INFECTIOUS DISEASES. 



parts of the abdomen. There may be a slight rise of temperature 
toward evening (Fig. 79) ; diarrhoea may alternate with constipation. 
The abdominal distention is the leading feature. It may take the 
form of a uniform ascitic accumulation (Fig. 80) ; the surface of 
the abdomen may be uneven and irregular (Fig. 81), and tumors 
with cystic formation may be felt through the abdominal walls. 

The movements, which are rich in fat, sometimes resemble icteric 
evacuations. This condition was formerly considered pathognomonic 
of tuberculous peritonitis (Biedert, Conitzer). 

Vomiting of faecal or biliary matter resembling that seen in appen- 
dicitis may occur. 

In marked contrast with these is a form which in its acute onset 
may simulate acute perforative peritonitis. In this variety the 
tubercle mass may cause perforation either of the appendix or the 





Fig. 79. 






DAY 1 2 3 


4 5 6 


7 


8 9 10 ^* 


hour .......S...S-.-S—S.. 


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Tuberculous peritonitis. Female child, five years of age. Ten days of her temperature 
immediately preceding operation (laparotomy). 



intestine. Symptoms of acute perforative peritonitis which in every 
way resemble those of appendicitis set in. It is only by resort to 
laparotomy that the nature of the affection can be discovered. 

Physical Signs. — The physical signs in the miliary and the nodular 
forms are due to the presence of free fluid in the abdominal cavity. 
If ascites is present, there will be the percussion-wave, the flatness in 
the flanks, and change of tympanitic area will occur with change in 
the position of the patient. If adhesions are present and there are 
encapsulations of fluid, the signs will not vary on changing the posi- 
tion of the patient. On the other hand, in the adhesive form there 
will be evidences of tumor masses in the abdominal cavity, cystic for- 
mations caused by the encapsulated exudate, and little or no fluid. 

In cases of adhesions in tuberculous peritonitis of the miliary 
form, the fact that when the patient is in the recumbent position the 
coils of gut may here and there be seen outlined over the abdominal 
parietes, is of diagnostic value (Fig. 81). I was able by this means 
to confirm the diagnosis of adhesions in one such case, and have 
detected them clinically in other cases in which this form of perito- 
nitis had been diagnosed. 



TUBERCULOSIS. 



429 



The liver may be enlarged as a result of amyloid degeneration or 
tuberculous interstitial hepatitis. 

The spleen may be enlarged as a result of amyloid degeneration. 
Rectal examination may reveal miliary nodules or peritoneal 
masses palpable through the walls of the rectum. 

Diagnosis. — The diagnosis is based on the slow and insidious 
onset, the colicky abdominal pains, abdominal tenderness on palpa- 
tion, the presence of ascites or tumor 
masses, constipation alternating with 
diarrhoea, progressive loss of strength, 
intermittent fever or slight rise of tem- 
perature in the evenings, and the pres- 
ence of tuberculosis in other organs. 
At the outset tuberculous infection in 
other parts of the body may be difficult 
of detection. A rectal examination 
should always be made. This form 
of peritonitis should be differentiated 
from the non-tuberculous form. Inas- 
much as some authors, notably linger 
and Nothnagel, doubt the occurrence 
of idiopathic non-tuberculous perito- 
nitis, caution should be exercised in 
making a diagnosis of simple chronic 
peritonitis. Absence of emaciation and 
retrogression of symptoms by no means 
prove that the disease may not have 
been tuberculous, since some forms of 
tuberculosis of the peritoneum present 
such peculiarities. 

This form of peritonitis must also 
be differentiated from cirrhosis of the 
liver, new growths, cardiac and renal 
affections. 

In some forms of tuberculous peritonitis, especially of the miliary 
type, the child will fail to show a temperature above the normal for 
weeks, and, being in tolerably good condition, the question will arise 
as to the nature of the abdominal process. In these cases a diagnosis 
is facilitated by the use of tuberculin. A reaction may be thus 
attained varying from a degree or more above the normal. The 
patient is placed in bed, the temperature previously observed every 
three hours for a few days, and is then given subcutaneously 0.-25 
milligramme of tuberculin. If no reaction takes place, 0.^0 mil 1 " 
gramme is given after a few davs. The dose nuiv bo increased 




Uniform abdominal distention due 
to ascites of tuberculous peritonitis ; 
enlarged spleen. 



I- 

to a 



430 



THE SPECIFIC INFECTIOUS DISEASES. 



milligramme with older children. A reaction takes place, if the 
process is tuberculous, within twenty-four hours ; though I have seen 
it delayed for forty-eight hours (Fig. 77). The cutaneous tuber- 
culin test is also applicable in these cases. 



Pig. 81 




Tuberculous peritonitis, miliary form, female child, five years of age. Irregular contour 
of abdominal parietes in the recumbent posture, showing intestinal agglutination. 

Course. — The course of the disease is chronic. Frequently the 
symptoms retrograde and there is an apparent recovery. The ascites 
may at times diminish, and again increase. The chronic forms 
unless operated upon lead to the formation of abdominal fistula?, to 
perforative peritonitis, to tuberculosis of the organs, and to amyloid 
degeneration of the liver and spleen, with emaciation, exhaustion, 
and death. 

Treatment. — Laparotomy, when there is no advanced tuberculosis 
in other organs, is, according to Herzfeld, curative in 54 per cent, 
of cases. In a series of 29 cases of all ages operated upon by 
him, 19 were under the age of fifteen years. With operative treat- 



TUBERCULOSIS. 



431 



ment must also be combined the medicinal and hygienic treatment 
suitable to cases of pulmonary or local tuberculosis. On the other 
hand, in the forms which resemble cases of tabes mesenteric a, in 
which emaciation and cachexia are present before much exudate is 
formed, it is difficult to decide as to the propriety of operative meas- 
ures, especially if diarrhoea be present. In these proper feeding 
should be begun and the condition of the patient improved before 
laparotomy is attempted. 

Tuberculosis of the Mesenteric Glands (Tabes Mesenterica). — 
Definition. — This term is applied to a set of cases in which we can 
clinically detect enlargement of the mesenteric lymph-nodes. There 
is wasting and fever without tuberculosis of the peritoneum. As a 

Fig. 82. 



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Tuberculin reaction. Miliary form of tuberculous peritonitis. Diagnosis confirmed by 
operation. Boy four years of age. 



clinical entity this condition is not common inasmuch as in 60 per 
cent, of all cases of tuberculosis there is associated tuberculosis of the 
mesenteric lymph-nodes. 

Pathogenesis. — In a recent inquiry into the frequency and types 
of primary tuberculosis of the mesenteric lymph-nodes, Hess found 
that in 60 per cent, of the cases the disease was caused by the bovine 
type of tubercle bacilli. This type was most frequent in children. 
In both children and adults these lymph-nodes may heal or retro- 
grade. In two cases reported by Hess the bacilli were of the human 
type. 

Symptoms. — In most of the cases there have been progressive wast- 
ing and colicy pains referred to the abdomen. These symptoms may 
extend over weeks or months. The pain is not severe, the children 
are ill-tempered, the appetite is capricious, there is diarrhoea alter- 
nating with constipation, and a low, irregular type o( temperature. 

Diagnosis. — The only positive evidence of the disease is the pres- 
ence of lymph-nodes on either side of the spine. They may be pal- 
pated at the level' of the umbilicus. 



432 THE SPECIFIC INFECTIOUS DISEASES. 

Prognosis. — The prognosis is good. I have seen cases recover 
completely. 

Treatment. — The treatment consists in a study of correct diet, 
hygienic surroundings and open-air life. There is no indication in 
the absence of complications for surgical interference. 

Other Forms of Tuberculosis. — Tuberculosis of the Larynx. — Tu- 
berculosis of the larynx is rare in children. It occurs in from 3 to 
4 per cent, of the total number of cases of tuberculosis (Reiner, 
StefTen, Barthez, Rilliet). Demme has reported a case in a child of 
four and one-half years. 

Tuberculosis of the Pleura and Pericardium. — Primary tuberculosis 
of the pleura is rare. Dennig reports that it occurred as a feature 
of general tuberculosis in 14 per cent, of his cases. Pericarditis of 
the tuberculous variety occurs in only 3 per cent, of the cases of gen- 
eral tuberculosis. 

Tuberculosis of the Heart. — Tuberculosis of the heart muscle is 
very uncommon. Sanger reports a case in a child of nine months, and 
Demme one in a patient of five years. The endocardium may be 
involved in general tuberculosis (Perroud). 

Tuberculous Meningitis (Acute Internal Hydrocephalus; Basilar 
Meningitis.) — Occurrence. — Tuberculous meningitis has been observed 
in infants as early as the third month (StefTen). Barthez and Rilliet 
have seen cases in infants five months old. The frequency of tuber- 
culous meningitis varies with the locality. Dennig places the fre- 
quency of tuberculous meningitis among children who suffer from 
tuberculous disease at 60 per cent., while Medin found this form of 
meningitis in 15 per cent, of tuberculous children. It is most fre- 
quent in the nursing period; 75 per cent, of all cases occur under 
the fifth year. The second year of infancy shows the greatest num- 
ber of cases (StefTen). It is more frequent among male than female 
children. 

Of 26 of my cases of tuberculous meningitis, substantiated either 
by autopsy or by the presence of tubercle bacilli in the fluid obtained 
by lumbar puncture, 46 per cent. (12) were under four years of age, 
53 per cent, were four years of age or over; the average age was four 
years and four months. The oldest case was ten years, and the 
youngest seven months. 

Etiology and Morbid Anatomy. — Exposure to cold and traumatism 
predispose to the affection. In many cases there is, in addition to 
the meningeal disease, disseminated tuberculosis of the lungs, pleura, 
spleen, liver, and peritoneum. In other cases the meninges are the 
chief seat of the disease, only a few isolated foci of tuberculosis being 
present elsewhere, as in the mesenteric or bronchial lymph-nodes. 
It is rare to find the lesions confined to the meninges, and some authors 



TUBERCULOSIS. 433 

deny the possibility of such a condition. It is not always possible 
to determine the primary focus of infection. 

The tubercle bacilli, which are the causative factors, may be 
carried by the blood (hsematogen) to the meninges, and there give 
rise to a more or less extensive miliary deposit. The original focus 
is involved in inflammatory exudate. The tissue of the cord and the 
nerve-elements may be the seat of degenerative processes. 

Symptoms. — The symptoms of tuberculous meningitis cannot be 
clearly classified according to stages. There is an indefinite period 
of premonitory symptoms followed rather abruptly by manifestations 
of cerebral irritation, and ending with a period in which pressure- 
symptoms are pronounced. As a rule, the disease is slow of develop- 
ment, although cases occur in which the rapid malignant course simu- 
lates that seen in rapidly fatal cerebrospinal meningitis of the epi- 
demic type. The disease gives a varying clinical picture in the 
different periods of childhood. 

The infant of from seven to twelve months refuses to nurse, has 
a low fever, and may have diarrhoea alternating with obstinate consti- 
pation. The illness of an infant is often attributed to a fall occur- 
ring while it is learning to walk. A weakness of the extremities is 
thus indicated. The infant becomes indifferent to its surroundings 
and passes into a somnolent condition. Emaciation is progressive. 
Vomiting occurs once or twice daily, the food being ejected from the 
mouth after nursing without apparent effort. The vomiting may be 
followed by a convulsion, after which the infant becomes unconscious. 
There may be strabismus, or rigidity of the extremities, or the ex- 
tremities may be in constant motion of an automatic character. The 
convulsions may follow one another without cessation. These symp- 
toms may set in after a period of one, two, or five weeks of ailing. 
In other cases the infant may have suffered from a chronic otorrhoea, 
although otherwise in apparent health. Suddenly, vomiting followed 
by a convulsion sets in. This convulsion is the forerunner of symp- 
toms, such as coma, which denote that the disease has become estab- 
lished without having attracted the notice of the parents. 

In children of five years of age the symptoms are more marked. 
The child may have an attack of vomiting and diarrhoea and appar- 
ently recover; after a few weeks, during which there are irritability, 
loss of appetite, and progressive emaciation, the child no longer desires 
to be up and about, but lies quiet in its crib, with its head in a char- 
acteristic rigid position. It develops strabismus, becomes soporose, 
and cries out at night. This cry is sometimes piercing in character, 
and is the cause of much concern to the mot her. When the symptoms 
of cerebral pressure are fully developed, the picture is in the majority 
of cases much the same. The infant after the firsl convulsion lies in 

28 



434 



TEE SPECIFIC INFECTIOUS DISEASES. 



a soporose or comatose condition. The eyes are open and there is a 
vacant stare ; the sclera may be apparent above the cornea ; the fonta- 
nelle if still open is tense and bulging, and there may be horizontal 
nystagmus. The infant cries if disturbed, or may be indifferent to its 
surroundings. The pupils may be unequal in size and react to light. 
In one case which I observed the pressure-symptoms were extreme. 
The infant lay on its back with rigid neck and arched back (opis- 
thotonos), and emitted a piercing cry at intervals. At each cry the 
pupils became successively dilated and contracted (hippus). I have 
seen this phenomenon in two cases of tuberculous meningitis. Opis- 
thotonos may be present, and the retraction of the head may relax at 



Fig. 83. 




\__ 




Babinski's reflex. Tuberculous meningitis ; stage of facial palsies. Boy seven years of age. 



intervals, the muscles of the back being lax. In some cases there is 
apparently no rigidity of the neck. As a rule there are no convul- 
sions. As the infant or child lies quietly in its crib the inspirations 
during the stage of cerebral pressure may be very irregular or may 
be of the Cheyne-Stokes type. The outline of the abdomen is at first 
normal or there may be a slight retraction at the upper part. The 
abdominal wall may be quite lax, so that the coils of gut can be made 
out. If the case is protracted, retraction of the abdomen occurs in 
the final stages of the disease. This condition has been described 
as the boat-like abdomen. It is not diagnostic of this form of 
meningitis. 



TUBERCULOSIS. 



4.'}. 



In rare cases spastic symptoms 
occur after the initial convulsion, 
rigidly flexed arms; the Chvo- 
stek and Trousseau symptoms 
are present. In all of these 
cases, if the skin is stroked with 
the finger ever so lightly, a red 
mark appears over the stroked 
area (tache cerebrate). In the 
spastic cases the knee-reflexes 
may be increased, but in the 
non-spastic cases they are di- 
minished. It is difficult to elicit 
Kernig's symptom in spastic 
cases, because the infants lie 
with the knees flexed. By 
straightening the legs and thighs 
it is possible in the majority of 
children to obtain the symptom. 

The most important symp- 
toms of the final stage of tuber- 
culous meningitis, both in in- 
fants and older children, are ^ 
the localized facial palsies. For . 
several days or weeks preceding £J 
the fatal issue, one side of the 
face is seen to be flatter than 
the other. There may be ptosis 
or lagophthalmus of the eyelids. 
One eye may be rotated inter- 
nally, owing to paralysis of the 
abducens. The extremities are 
also paretic. The arm and leg 
of one side may be rigid or 
flexed, while those of the oppo- 
site side are lax. 

Irritation of the soles of the 
feet may give a Babinski reac- 
tion (Fig. 83). In some cases 
this reaction is present inde- 
pendently of any irritation of 
the plantar surface. Toward 
the end, convulsive twitchings 
appear in the muscles of one 



closely resembling those of tetany 
The infant lies comatose, with 



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436 



THE SPECIFIC INFECTIOUS DISEASES. 



or the other side of the face or of the extremities. Death supervenes 
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unsteady gait, and has no desire to study or play. 

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left side of the chest and had lost weight steadily. There were mild 
pleurisy and signs of slight consolidation at the apex of the left lung. 
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Tuberculous meningitis, observed from the outset of the symptoms. Female infant, 

fourteen months old. 



mild type, the emaciation was progressive and the leucocyte counts 
low (8000 W.B.C.). At night the typical cry of tuberculous menin- 
gitis was present. In the early stages of the disease the patient was 
conscious duriug the day, but later became listless, irritable, and 
slept or was drowsy during the day. When questioned, a slow, stupid 
answer was given. The child vomited and at times became nau- 
seated. The Kernig symptom appeared. Eight lagophthalmos was 
present. The pupils were unequal in size, the left being dilated. 
The pulse at this time varied from 60 to 100 and was compressible. 
Finally, coma set in with left facial palsy and convulsive twitchings 
of the left side of the face. This case was for three months under 
constant observation. In other cases the vomiting is rapidly fol- 



TUBEBCULOSIS. 



437 



lowed by paralytic symptoms such as ptosis and facial paralysis on 
the same side. There are no convulsions and no cry, but there is 
rigidity of the neck and extremities; one patellar reflex may be 
absent. The Kernig symptom and Babinski reflex are present in 
the majority of cases in children. 

The very rapid and fatal cases of tuberculous meningitis have 
been described by Osier and Dennig. In these the patient is over- 
whelmed by the toxaemia of the disease, no marked tuberculous lesion 
being present in any organ but the brain. A patient in apparently 
good health is suddenly seized with convulsions followed by a period 

Fig. 86. 



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Tuberculous meningitis : general miliary tuberculosis : terminal stage ; coma and 
paralysis. Boy, seven years of age. 



of unconsciousness. There are muscular relaxation and a vacant 
stare. The convulsions may be repeated at intervals of a few minutes 
or half an hour. There then follow opisthotonos and spasms, and 
the abdomen is tympanitic. There is neither vomiting, tache, nor 
elevation of temperature. There are spastic contractures of the 
extremities alternating with relaxations. Death occurs in a convul- 
sive seizure within ten hours. 

Schlessinger reports a case of tuberculous meningitis in a child 
two and a half years old, setting in with convulsions, followed by 
hemiplegia and aphasia within thirty-six hours. After those pre- 
monitory phenomena the ordinary symptoms o( the disease appeared. 
Such cases arc 4 exceedingly rare. 

The temperature-curve in tuberculous meningitis is not eharao- 



438 THE SPECIFIC INFECTIOUS DISEASES. 

teristic. In some cases the temperature will not rise more than a 
degree or two above the normal, intermitting to the normal or nearly 
so. In other cases it may be normal for days, then rise a degree or 
more, rarely above 103° 'F. (39.4° C), and then fall again to the 
normal. In cases in which there is a general miliary process the 
temperature mounts to 105°-106° F. (40.5°-41.1° C.) or higher 
toward the close. The fatal issue in other cases occurs with a sub- 
normal temperature (96° F., 35.5° C.) lasting for a day or more 
before death. If the case is a protracted one, the normal diurnal 
variations may be reversed — that is to say, the highest temperature 
may be reached in the morning hours and the lowest toward evening. 
In the majority of cases, however, the temperature is rarely higher 
than 103° F. (30.4° C.). 

The pulse is increased at the onset, but during the course of the 
disease becomes slow and may range from 60 to 100 or more during 
the twenty-four hours. 

The respirations are irregular, and may vary from 18 to 60 
within the twenty-four hours, even if no pulmonary lesion is present. 

Individual Symptoms. — Onset. — Of 26 cases which I have utilized 
for the purposes of this article, the onset was slow and insidious in 
77 per cent. The mother of the child related that the patient was 
not quite well, or complained of slight headache, and vomited from 
time to time before the appearance of marked symptoms. In those 
cases which have come under my observation early in the disease, as 
early as the second day after marked symptoms were observed by 
the parents, there was no history of vomiting; as a rule, the child 
had a slight elevation of temperature, was irritable from time to time, 
refused to nurse, and on the whole the mother observed a change in 
the general attitude of the child toward herself and others. It was 
only in those cases which had lasted at least a week that there was a 
history' of vomiting. It was only in exceptional cases that the 
mother asserted the disease began suddenly with vomiting and 
convulsions. 

Vomiting. — Vomiting sets in, on the average, eighteen days 
before the fatal issue, and may occur once or twice daily. It may be 
absent in some cases. With the vomiting there may be localized con- 
vulsions, which appear with the vomiting, as has been stated in 
exceptional cases in which the onset is sudden, or may appear two 
weeks after the initial vomiting attack. 

Rigidity.- — There are some cases of tuberculous meningitis in 
which rigidity of the neck is absent throughout the disease. In only 
one of my cases was there opisthotonos ; and the rigidity, if present, 
as a rule, was but slightly marked; that is, the head was movable 
almost to a normal degree. The rigidity is tested simply as the child 



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TUBERCULOSIS. 439 

lies in bed; the head is raised, or an attempt made to draw the chin 
toward the sternum and note the resistance. In only 25 per cent, 
of the cases was there palpable rigidity or stiffness of the neck, and 
this appeared late in the course of the disease. 

Hyperesthesia. — Hyperesthesia, either of the surface or of the 
senses, is absent, as a rule, in tuberculous meningitis; that is, the 
child reacts feebly or not at all to irritation, and, when roused, 
momentarily protests and then falls into sopor again. In 90 per cent, 
of the cases there was an absence of hyperesthesia either of the sur- 
face or of the senses; and in this respect tuberculous meningitis is 
quite the opposite of cerebrospinal forms of purulent meningitis of 
the epidemic type, in which hyperesthesia is the rule and forms part 
of the general symptomatology of the disease. 

Kernig Symptom. — This symptom is present in only 50 per cent, 
of the cases. Its presence or absence does not materially aid in the 
diagnosis. 

Babinski Reflex. — In children over two years of age the Babinski 
reflex is a valuable guide clinically as to the nature of a menin- 
gitis, if meningeal symptoms are present; more so than the Kernig 
symptom. 

Of 26 cases of tuberculous meningitis, the Babinski reflex was 
present in 15. It is found exceptionally in the cerebrospinal menin- 
gitis of the epidemic type, or the suppurative forms of meningitis. 

The general reflexes are present in tuberculous meningitis early 
in the disease ; whereas late in the disease, when paralysis supervenes, 
they are absent. 

Pulse. — The irregularity of the pulse is of no special diagnostic 
value in tuberculous meningitis, and if present is only incidental. 
The irregularity of the pulse is quite a feature in other forms of 
meningitis, especially of the cerebrospinal type. In these cases the 
pulse at one moment may be 85, and immediately after may suddenly 
mount to 120 beats a minute. In tuberculous meningitis, however, 
the pulse, as a rule, is slower than that of meningitis of the cerebro- 
spinal type. 

Respiration. — The respiration is irregular in most forms of men- 
ingeal trouble in children. In the tuberculous form of meningitis, 
after the disease is well inaugurated, the respirations are irregular 
and shallow, and in a few cases, where cerebral pressure is very 
marked late in the disease, the respirations may assume the so-called 
Cheyne-Stokes rhythm. The irregularity of respiration or pulse is 
scarcely an aid as to differentia] diagnosis o\' the form of meningitis 
present. 

Temperature. — Of greater utility in the diagnosis is an exact 
observation of the course of the temperature. Although there are 



440 TEE SPECIFIC INFECTIOUS DISEASES. 

cases of tuberculous meningitis in which the temperature ranges as 
high as 104° to 105° F., this high temperature is present only in 
the presence of complications of the lung, or at a late period of the 
disease, toward the fatal issue. In most cases of tuberculous menin- 
gitis which I have seen, a low range of temperature has been the rule. 

Blood. — In all my cases of tuberculous meningitis I have had the 
blood examined at intervals of three days ; in two-thirds of the cases 
there was a leucocyte count ranging below 20,000 to the cubic milli- 
metre. In the remainder of the cases, however, I obtained a leucocyte 
count ranging from 20,000 to 25,000 to the cubic millimetre. In 
some cases there was at some period of the disease a so-called leuco- 
penia. In no case except one, in which the leucocytes just before the 
fatal issue mounted to 32,000 to the cubic millimetre, did the leuco- 
cyte count exceed 25,000 to the cubic millimetre; therefore a leuko- 
penia, however presumptive evidence in the face of other symptoms 
of the tuberculous form of meningitis, is certainly not a positive evi- 
dence of the presence of the disease. The lowest count in my cases 
was 5000 leucocytes to the cubic millimetre. 

Eyes. — The condition of the fundus of the eyes is of special 
interest in this form of meningitis, as compared with the condition of 
the disk and retina in other types, such as the cerebrospinal form of 
meningitis. In 20 consecutive cases of tuberculous meningitis exam- 
ined by the expert ophthalmologist in my hospital service, the fundus 
was normal at an early or late period of the disease in 25 per cent, 
of the cases. In 75 per cent, of the cases, however, there was some 
change in the disk (optic neuritis), or there were present also tuber- 
cles in the choroid. In some cases the disk was simply swollen, and 
indistinct at the margin; in other cases the veins were congested. 
Tubercle was found in the choroid in 6 of the 20 cases examined. 
Choroid tubercle was seen as early as the first and as late as the sixth 
week of the disease. 

The cerebral cry present at night is not distinctive of this form 
of meningitis; the emaciation, the retraction of the abdomen, the 
bulging of the fontanelle may be present in other forms of menin- 
gitis, especially in that form described by English authors as the 
posterior-basic form. Of great service in making a clinical diagnosis 
in this disease is the presence of palsies of the cranial nerves, facial 
paralysis; ptosis, strabismus, paralysis of the internal rectus of one 
side, or ptosis of one side with or without lagophthalmos of the oppo- 
site side, are indicative of a lesion at the base of the brain. These 
palsies are seen more frequently in the tuberculous forms of menin- 
gitis than in the epidemic cerebrospinal type of meningitis. I have, 
however, seen these palsies in cases of cerebrospinal meningitis either 



TUBERCULOSIS. 441 

in infants or children, and in these cases the palsies appeared early 
in the disease rather than late, as in the tuberculous form. 

Macewen s Sign.- — This sign is elicited by percussion along the 
parietal or frontal bone over the situation of the anterior horn of the 
ventricles, and in infants and children below two years of age is of 
very little value as to the diagnosis of tuberculous meningitis with 
consequent accumulation of fluid in the ventricle as a result of this 
disease, inasmuch as in certain children suffering from pronounced 
rachitis with slight accumulation of fluid in the ventricles, so-called 
hydrocephalus, this tympanitic note of Macewen may be obtained. 
The Macewen tympanitic note is therefore of value only in children 
above two years of age, and must always be sought by sitting the 
patient upright in bed, inclining the head toward one or the other 
shoulder, and percussing the inferior side of the skull over the parietal 
or frontal bone. When carried out in this manner, a marked tympa- 
nitic note over the anterior horn of the ventricle is presumptive evi- 
dence of fluid in the same as a result of inflammatory processes at the 
base of the brain and obstruction of the veins of Galen. 

Lumbar Puncture. — Lumbar puncture is to-day the most valuable 
aid we possess in making a positive diagnosis of the various forms 
of meningitis. In tuberculous meningitis there has been discussion 
as to the value of an examination of the puncture fluid in the diag- 
nosis. First, as to the cyto diagnosis, it may be said that in 15 of 
my cases of tuberculous meningitis studied with a view of noting the 
character of the cell elements in the puncture fluid, 14 showed a pre- 
dominance of mononuclear cells. In 1 case there was an equal num- 
ber of mononuclear and polynuclear cells. It would seem, therefore, 
that in tuberculous meningitis there is a prevalence of mononuclear 
cells, and that this is so constant that it would appear to be charac- 
teristic. There are forms of cerebrospinal meningitis, however, espe- 
cially the chronic cases, and those of the posterior-basic type of long 
duration, in which, instead of a polynuclear picture in the sediment 
of the fluid obtained by lumbar puncture, the mononuclear picture is 
apt to present itself, thus closely resembling what is seen in tuber- 
culous meningitis. 

The bacteriology of the fluid obtained from cases of tuberculous 
meningitis by means of lumbar puncture has been a matter of close 
study and difference of opinion; whereas Lichtheim, Lenhartz, and 
Bernheim found that tubercle bacilli were constant in the sediment 
of the fluid obtained from these cases; Cassell and Marfan have 
asserted that their presence is only occasional. Of late we have 
examined the puncture fluid of 14 consecutive cases of tuberculous 
meningitis, which were clinically diagnosed as tuberculous in char- 
acter before the puncture. In 13 of these eases tubercle bacilli 



442 THE SPECIFIC INFECTIOUS DISEASES. 

were found by Bernstein of the hospital laboratory. The fluids 
were carefully centrifuged, and the search was exceedingly pains- 
taking. In some cases, especially of children coming under obser- 
vation late in the disease, tubercle bacilli were not found during 
life in the puncture fluid, but were found postmortem. This is 
explained by the fact that in these cases the tubercle bacilli were 
present in but few numbers which during life were kept evenly dis- 
tributed throughout the subarachnoid space, and were found in the 
puncture fluid only after prolonged search. I am inclined to believe 
that the search for tubercle bacilli in the puncture fluid obtained from 
cases of tuberculous meningitis is the most positive and valuable aid 
to the diagnosis, and the bacilli can be found in the majority of cases, 
if carefully looked for. 

Tuberculin Test. — Finally the cutaneous tuberculin test is of 
great value in the early stages of the disease in arriving at a diagnosis. 

Differential Diagnosis. — Tuberculous meningitis must be differen- 
tiated from epidemic cerebrospinal meningitis or sporadic cerebro- 
spinal meningitis, suppurative forms of meningitis, posterior-basic 
meningitis, polioencephalitis, apex pneumonia, typhoid fever, sepsis, 
disturbances of the stomach and gut, uraemia, helminthiasis, and 
finally the various forms of otitis. From cerebrospinal meningitis 
it can be differentiated by the slow onset, by the absence of opistho- 
tonos, and in the majority of cases a slight rigidity of the neck, by 
the absence of hyperesthesia, the presence of changes in the fundus 
of the eye, other optic neuritis or the presence of choroid tubercle, 
which will be absent in cases of cerebrospinal meningitis and posterior- 
basic meningitis, by the low range of the temperature, by the absence 
of a leucocytosis above 25,000 to the cubic millimetre, and finally by 
the results of an examination of the fluid obtained by lumbar puncture. 

Pneumonia with cerebral symptoms may simulate tuberculous 
meningitis. Here again the history and the character of the delirium 
in older patients will aid us. The signs in the lung and the presence 
of leucocytosis, which is marked in pneumonia and generally absent 
in tuberculous disease, are significant. In the majority of cases of 
typhoid fever the history will be of service in connection with the 
roseola, the Widal reaction, the enlarged spleen, and the absence of 
leucocytosis. Diarrhoea may be present in typhoid. 

Disturbances of the gut, uraemia, and helminthiasis may present 
symptoms resembling those of tuberculous meningitis, but the symp- 
toms in time retrograde or are cleared up by a study of the case. 

I have seen otitis media in nurslings with very limited areas of 
bronchopneumonia, simulate tuberculous meningitis. In these cases 
the infants may have been ill for two weeks or more. They start from 
sleep, are irritable on awakening, and lose appetite. 



TUBERCULOSIS. 444 

In one case the ocular symptoms closely simulated those of tuber- 
culous meningitis. As a rule there are intervals during which the 
child is not only free from pain, but also has a normal temperature. 
At other times the temperature has a septic intermittent character, 
and mounts higher (104° F., 40° C.) than in tuberculous meningitis. 
Aural examination only will remove doubt. 

Duration. — The duration of the disease varies within wide limits ; 
I have seen cases which extended over three months. The majority 
of cases last from two to three weeks, but cases lasting five weeks are 
not unusual. The very rapid cases in which death ensued within 
twenty-four hours have been mentioned. 

Prognosis. — The prognosis is usually fatal. Isolated cases of 
recovery have been reported. Martin has recently collected some 
twenty cases of undoubted tuberculous meningitis which recovered 
or had periods of complete remission of symptoms extending over 
years. In some of these cases the lesion in the meninges subse- 
quently became a focus of fresh infection which terminated fatally. 

Treatment. — The treatment is directed to alleviating the suffer- 
ings of the patient. Lumbar puncture is not curative, and should 
not be repeated after the first diagnostic puncture has been per- 
formed. 

Tuberculosis of the Brain (Solitary Tubercle of the Brain). — 
In this there may be a single localized tuberculous nodule or mass in 
the brain, or several such formations may be present. Demme found 
a growth of this kind in an infant twenty-three days old. Henoch 
has published a case in an infant eleven days old. The majority of 
cases occur between the second and the fifth year. 

Morbid Anatomy. — Tubercle bacilli of diminished virulence and 
limited number are carried from the focus of tuberculosis to the brain 
through the blood-channels, and there lodged in a terminal blood- 
vessel, forming solitary tuberculous masses varying from the size of 
a pea to that of a hazelnut. These are surrounded by a zone of 
granulation-tissue. The neuroglia in the immediate vicinity is the 
seat of proliferation, and may form a capsule around the growth. 
Circumscribed meningitis over the situation of the growth, with adhe- 
sions of the pia mater to the dura, may be present. Fully half of 
these solitary growths occur in the cerebellum (Gerhardt), The 
growth may be single or there may be one large growth and several 
of smaller size. Starr and Seidl found a solitary growth in 77 per 
cent, of the cases. The larger number of brain tumors in infancy 
and children are tuberculous, Starr found this variety in 152 our 
of 300 cases of all kinds o( tumors. 

The symptoms are those common to all tumors, and will be de- 
scribed in the section denoted to Brain Tumors. 



444 THE SPECIFIC INFECTIOUS DISEASES. 

SYPHILIS. 

Acquired Syphilis of Infancy and Childhood. — Definition. — Syph- 
ilis is an infections disease caused by the Spirochseta pallida of 
Schaudinn and Hoffman. The spirochsetae are found in the blood 
and luetic lesions. 

Mode of Infection. — Of 42 cases of acquired syphilis collected by 
Fournier, 19 were infected by the father or mother after birth, and 
8 by the nurse. ~No case was infected in passing through the mater- 
nal parts, and no infant was infected by the mother if she had 
contracted the disease prior to her accouchement. A child of a syphi- 
litic mother, if born free from signs of syphilis, cannot contract a 
primary lesion at birth from the maternal parts, even if these parts 
are the seat of condylomata, nor can such an infant be infected sub- 
sequent to birth. It has an acquired immunity against the disease. 

A chancre or primary lesion is, in the infant as in the adult, the 
only evidence of acquired syphilis. It is the result of infection, and 
must be present in order that the diagnosis may be certain. Chancres 
are rarely genital. They are found, as a rule, in the mouth, on the 
face, and on the abdomen and perineum. An infant may be infected 
by the nipple of the nurse's breast. The act of kissing, contaminated 
nipples of the nursing-bottle, instruments, sponges, ritual circum- 
cision, and humanized vaccine virus, are all means of infecting the 
infant. Since humanized vaccine virus is no longer used, this mode 
of infection has been eliminated. 

Symptoms. — The symptoms consist of a chancre or initial lesion, 
rarely genital, which appears three or four weeks after inoculation. 
The other accidents, such as bubo or adenopathies, the eruption, and 
all the secondary symptoms of acquired syphilis, appear in due course 
as in the adult. The genital chancre is seen in infections caused by 
ritual circumcision. 

Prognosis. — The prognosis as to life is good in comparison with that 
in the hereditary form of the disease. While in the hereditary form 
the mortality is from 70 to 80 per cent., that in the acquired form 
is very low. Fournier lost only 1 in 42 cases of acquired syphilis. 
The course in infants and children is benign. The chancre is not 
well developed ; the induration is present only a short time, or may 
even escape notice. The infants enjoy good health in spite of the 
presence of the secondary symptoms. I have confirmed these state- 
ments by observing 7 cases of genital chancre. The tertiary mani- 
festations, such as gummata, bone lesions, joint-affections, eye and 
laryngeal symptoms, and cerebrospinal lesions, appear from five to 
twenty-five years after the initial lesion. 

Differential Diagnosis. — Acquired syphilis must be differentiated 



SYPHILIS. 445 

from the hereditary form of the disease. Hereditary or congenital 
syphilis appears early without an initial lesion, showing general sec- 
ondary symptoms from four to six weeks after birth. The chancre 
is the first manifestation in acquired syphilis. In Fournier's 42 
cases the chancre appeared during the first year of life in 19, and 
during the second year in 10 cases. The snuffles, pemphigus, and 
pseudoparalysis are not present in acquired syphilis. Secondary 
accidents, such as mucous patches or papules about the genitals, 
appearing during later childhood are probably traceable to a post- 
natal infection. Interstitial keratitis, bone syphilis, and cutaneous 
stigmata are common to the hereditary and acquired forms of the 
disease. It is sometimes very difficult to decide which form of the 
disease is present. Thus far no one has shown conclusively that 
Hutchinson's teeth are present in acquired forms of syphilis in in- 
fancy and childhood. Their presence is therefore strong presumptive 
evidence of hereditary syphilis. 

Late Hereditary Syphilis (Syphilis Hereditaria Tarda). — 
Definition. — Fournier defines late hereditary syphilis as a symptom- 
complex of accidents of syphilis originating in a hereditary infection, 
which manifests itself at a more or less advanced period of life, that 
is to say, in the majority of cases between the third and the twenty- 
eighth year. 

Classification. — There are two classes of cases. In the first, the 
patient has remained in perfect health without any of the eruptive 
or other symptoms of hereditary syphilis until at an advanced period 
of childhood one or more of the symptoms of late hereditary syphilis 
are developed. In the second, the late symptoms have been preceded 
by the early symptoms of hereditary syphilis. The late symptoms 
may develop after an interval of from ten to fifteen years. The cases 
of the former class have been the subject of much discussion. The 
occurrence of the second class of cases is now well established ; it is 
often very difficult to determine the hereditary or acquired nature of 
the original infection. 

Symptoms. — Fournier, in classifying the symptoms of 212 eases 
of late hereditary syphilis, found the eye to be the organ most fre- 
quently affected. Next in order of frequency are the lesions of the 
bones and skin. The rarer affections are those of the kidney, larynx. 
spinal cord, testes, and lungs. 

The subjects of late hereditary syphilis have certain well-defined 
general characteristics. They are constitutionally delicate and have 
an emaciated habitus. The skin presents a grayish aiuvmia. There 
is an arrest in the development of bone and musculature. The men 
are undersized and present the picture which has been character 
as infantilism. The signs of virility, such as the beard, hair under 



446 



THE SPECIFIC INFECTIOUS DISEASES. 



the arm and on the pubes, are scantily developed. The testes are 
rudimentary. The adult has the appearance of a boy of fourteen 
or fifteen years. The women are correspondingly backward in devel- 
opment. 

The Eye. — The eye symptoms appear most frequently at the age 
of ten or fifteen years, but may become evident as early as the third 
year. The principal symptom is a keratitis of the diffuse intersti- 
tial variety, the so-called keratitis of Hutchinson. The cornea has a 
slightly cloudy or filmy appearance, or the whole structure is diffusely 

Fig. 87. 




Late hereditary syphilis ; bone deformity and sinus. Child, three years of age. 



opaque. The other ocular accidents are plastic iritis, which fixes the 
iris, thus limiting its action and causing a difference in the size of the 
pupils. The rarest manifestations are miliary gummata of the iris. 

Bone-lesions. — The bone-lesions are most frequent between the 
fifth and the twelfth year. 

The head presents a cuboidal shape; the forehead is prominent; 
the frontal bones have large bosses, as have also the parietal bones. 
The longitudinal suture is depressed, giving a natiform shape to the 
head. The cranium may have the form seen in mild degrees of 
hydrocephalus. 

The nose, on account of the destruction of the bony septum, has 
a depressed bridge. The bony and cartilaginous septa form an acute 
angle, and a peculiar retrousse appearance is given to the organ. 



SYPHILIS. 



447 



Both bony and cartilaginous septa may be destroyed. The whole 
organ is flattened, the tip of the nose being wrinkled into three or 
more folds. 

The long bones are especially affected by the accidents of late 
hereditary syphilis, the tibia being most frequently affected. The 
lesion may consist in an osteoperiostitis, a gummatous osteoperiostitis, 
or a gummatous osteomyelitis. 

If osteoperiostitis is present, there are diffuse swelling and thick- 
ening of the bone — the so-called sabre-like deformity (Fig. 87). 
This process may affect the long bones of the upper extremities. The 
gummatous lesions of osteoperiostitis form numerous irregular pain- 
ful swellings on the bone. Gummata are present on the flat bones of 
the cranium. When these break down, the destructive processes may 
expose the dura mater. Arthropathies with synovitis may be mis- 
taken for tuberculosis of the joint. This form of synovitis is gener- 

Fig. 88. 




Radius affected with osteoperiostitis due to late syphilis 



ally bilateral. One of my cases, a child five years of age, gave no 
history of syphilis. The radius on both sides was affected by osteo- 
periostitis (Fig. 88). The joints may be deformed by osteophytic 
growths involving the epiphysis or head of the bone. 

Ear. — The ear is affected by an otitis with destruction of the 
ossicles, and even by mastoid disease. In other cases deafness super- 
venes without premonitory symptoms. 

Shin and Mucous Membranes. — The skin and mucous membranes 
show certain stigmata in the form of cicatrices of recenl or old ulcera- 
tions. These may exist on any part of the body, but are especially 
characteristic on the vermilion border o( the lips and at the corners 
of the mouth, where they are seen as radiating, linear pale-white 
fissures. 

Lymph-nodes. — The lymph-nodes may be enlarged, especially 



448 TEE SPECIFIC INFECTIOUS DISEASES. 

those on each side of the neck, below the jaw, and in the axilla and 
inguinal regions. 

Spleen. — The spleen is enlarged, but not so frequently as is stated 
by some authors. Fournier found it enlarged in 15 out of 212 cases. 

Liver. — The liver was enlarged in 25 cases. In one of my cases 
of late hereditary syphilis in a child eight years of age, postmortem 
examination revealed cirrhosis of the liver of the hypertrophic type. 
There were enlargement of the spleen, icterus, and ascites ; Hutchin- 
son's teeth were well marked, and there were also adenopathies and 
changes in the bloodvessels. 

Mental and Other Symptoms. — Fournier among others has de- 
scribed forms of idiocy and epilepsy of syphilitic origin, but there is 
great difference of opinion on this question. The theory of Parrot, 
that rachitis is the result of syphilis, is now generally abandoned. 
The deformities of the teeth which occur in late hereditary syphilis 
will be found fully described in the section devoted to Dentition. 

Congenital or Hereditary Syphilis.— Etiology. — Congenital or 
hereditary syphilis results from the infection of the ovule or foetus 
in utero. This may occur in a number of ways, but in the great 
majority of instances it results from infection of the foetus through 
the father. The more recent the syphilis of the father, the more 
likely is the infection to occur. It is most certain to occur if both 
the father and mother suffer from recent syphilis at the time of con- 
ception. The father may at the time of insemination suffer from 
recent syphilis and the mother be healthy. Under such conditions 
the child is born syphilitic. The mother may not show any signs of 
active syphilis either during pregnancy or at any subsequent period. 
The mother may suckle her offspring, which shows all the marks of 
active hereditary syphilis, without becoming infected, but the child 
will infect any strange nurse. The mother has during pregnancy 
acquired an immunity against the infection. This phenomenon, 
which is a matter of daily observation, was first brought to the notice 
of the profession by the distinguished surgeon Colles, and has since 
become known as Colles's law. The longer the mother is subjected 
to the influence of the syphilitic virus, the more permanent does her 
immunity become. Thus a mother who has at first miscarried may 
eventually give birth to a living infant which bears the marks of 
syphilis. As the virus becomes weakened, the mother may bear an 
infant to all appearances healthy. In the interval, although repeat- 
edly pregnant, the mother has shown no signs of active syphilis. 

If the father is healthy at the time of insemination and the 
mother the subject of recent syphilis, the infant will be born syphilitic. 
On the other hand, if the mother contracts syphilis after conception, 
the father at the time of conception having been healthy, the infant 



SYPHILIS. 449 

may or may not be born syphilitic. The nearer the time of the infec- 
tion of the mother to the end of her period of pregnancy, the more 
likely is the infant to escape (Monti, Zeissel, Hutchinson). Such an 
infant if born healthy may become infected in the ordinary way from 
the mother after birth. 

A father who has passed through the secondary manifestations of 
syphilis may in the late secondary period or tertiary stage fail to 
convey the poison in the sperma. The result will be an infant free 
from syphilis (Fournier, Neuman). Yet so far-reaching is the influ- 
ence of the syphilitic dyscrasia that such an infant, although born 
healthy and at no time showing signs of syphilis, may present certain 
signs, such as peculiarities of bone formation (teeth) traceable to the 
syphilitic virus (parasyphilitic). 

Exceptions to Colles's law occur, as is to be expected. Fournier 
has recorded cases in which mothers apparently immune have devel- 
oped signs of secondary syphilis after the birth of the infant. Finger 
has met cases in which tertiary syphilis developed in the mother sub- 
sequent to pregnancy without the occurrence in her of any of the 
signs of secondary syphilis. 

Of 218 mothers who had borne syphilitic infants, Hochsinger 
found 72 who were free from manifestations of secondary or tertiary 
syphilis although observed for years. 

Morbid Anatomy. — In considering the pathology of hereditary 
syphilis, Hochsinger divides the cases into four classes : 

The first class of cases die in utero before the eighth month. 
Autopsies upon such foetuses show general parenchymatous involve- 
ment of the glandular apparatus with epiphyseal osteochondritis. 

The second class includes infants born living or dead before the 
end of pregnancy. They present at birth a papulobulloUs syphilide. 
In these cases diffuse parenchymatous changes are found in the vis- 
cera, and frequently marked epiphysitis. 

The third class comprises infants born living and without any 
exanthema, but which later develop an exanthema independently of 
visceral or bony changes. 

The fourth class comprises infants born without an exanthema, 
but having at birth marked visceral and bone-changes. 

The lesions as found in the various parts of the body, in detail, 
are as follows : 

Shin. — We find that the skin shows an increase in the thickness 
of the rete Malpighii, caused by swelling of the cells of the rete, serous 
infiltration of this layer, and an increase o( the spaces between the 
cells of the rete. The horny layer oi' the skin is much thinned in 
comparison, although there is a constanl throwing-off of the cells ot 
this layer in lamellae. The epithelium of the sweat-glands is swollen 

20 



450 THE SPECIFIC INFECTIOUS DISEASES. 

and there is a small round-cell infiltration between the glands. There 
is a vasculitis of the small bloodvessels affecting the external coat 
chiefly. Pemphigus and bullae result from infiltration of the rete 
and the lifting up and separation of the horny from the papillary 
layer by serum. 

The Lungs. — The changes in the lungs may be considered under 
two heads : 

First, the lungs of infants born dead or who have died soon after 
birth, are collapsed, devoid of air, hypersemic, and dark red in color. 
In rare cases the lungs may be diffusely whitish yellow in color, 
giving the appearance of the so-called pneumonia alba. The second 
class comprises infants that have breathed, and that show a gray or 
grayish-white discoloration of the lungs in places. There is residual 
air in the lungs, and they are denser and larger than is normal. 

Ziegler has shown that the changes in the lungs consist chiefly in 
an increase in the interalveolar connective tissue, the formation of 
new vessels, and vasculitis of the bloodvessels. In the majority of 
newly born infants the alveolar epithelium is but little affected. In 
pneumonia alba there is a proliferation of the alveolar epithelium, 
giving a peculiar appearance and color, hence the name. 

The Liver. — Changes in the liver are quite constant in hereditary 
syphilis. These may or may not be associated with enlargement of 
the organ. Out of 148 cases of congenital syphilis, Hochsinger found 
the liver enlarged in 46 ; in all but 2 the spleen also was enlarged : in 
the severer cases the - liver was markedly enlarged. 

The pathological changes in the liver have been described by 
Hudelo, Hochsinger, and Heller. There may be simply diffuse. 
small round-cell infiltration of the interstitial connective tissue, with 
inflammatory changes in the smaller arteries. The liver in these 
cases is not enlarged. In the cases presenting an enlarged liver there 
is interacinous proliferation of connective tissue, beginning at the 
periportal region and following the course of the bloodvessels. There 
is vasculitis, shown in a thickening of the adventitia of the blood- 
vessels. The parenchyma is degenerated. In other cases interacinous 
collections of small round cells are on gross sections of the liver seen 
as yellow pinhead-sized spots. These are called by Hochsinger miliary 
gummata. Fully developed gummata of large size are very rare in 
the liver of infants affected with hereditary syphilis. 

Spleen. — The spleen is in some cases enlarged to ten times its 
normal size. Gummata, single or multiple, occur, but are rare. In 
hereditary syphilis not only is the parenchyma increased, but also 
the connective tissue of the spleen. 

Kidneys. — In rare cases there are induration and contraction of 



PLATE XXVI 




Congenital Syphilis. Showing nasal deformity. 
Newborn infant. 



SYPHILIS. 4~)\ 

the kidney. The parenchyma is retarded in development by intra- 
uterine syphilis and the connective tissue increased. 

Pancreas. — The pancreas may be enlarged and infiltrated, the 
parenchyma hard, and the interstitial connective tissue increased. 
There may be condylomatous ulcerations on the tongue, pharynx, 
and tonsil. 

Glandular Apparatus. — According to Hochsinger, the glandular 
apparatus of the gut may show a diffuse small-cell infiltration, 
Peyer's patches may be infiltrated, and the vessels may be the seat 
of a vasculitis. The lymph-nodes are, as a rule, little changed except 
in cases with late manifestations. The thymus gland in cases of 
hereditary syphilis has been found to be the seat of cystic degenera- 
tion (Eberle, Ribbert), caused by the dilated epithelial spaces of the 
foetal thymus. 

Bone-changes. — The bone-changes in hereditary syphilis occur 
principally at that part of the bone between the epiphysis and 
diaphysis in the lower end of the femur, tibia, and radius. In the 
milder forms of bone-change there is, according to Ziegler, little real 
inflammation. There are irregularity in the deposit of lime salts 
and the formation of marrow-spaces. In severe forms there is a true 
inflammatory process. In the vicinity of the joint-cartilage, grayish- 
red, yellowish-white, or yellowish-green foci of osteomyelitis are 
found. The irregular deposit of lime salts and the formation of 
marrow-spaces are evidenced by reddish-yellow projections of marrow- 
spaces into the adjacent proliferated cartilage. These give the epi- 
physeal junction a more irregular and widened appearance than is 
normal. Sometimes separation of the epiphysis at the junction of 
the diaphysis occurs. The above changes are frequent, although not 
constant. In the later stages of syphilis in children there are, as in 
the adult, caries, necrosis, and gumma formations in the long and 
flat cranial bones. 

Symptoms. — The symptomatology of hereditary syphilis varies 
largely with the class of cases. In some cases the foetus is expelled 
dead, bearing the marks of fully developed syphilis in the shape of 
skin, bone, and visceral lesions. In others the infant is born living, 
but presents a few very characteristic signs of syphilis, such as the 
presence of bullae or pemphigus either on the palms or on the soles of 
the feet. The vesicles may be filled with a purulent fluid. As a rule 
these infants are emaciated. In some cases the bridge of the nose is 
sharply depressed and forms a distind angle with the cartilaginous 
septum (Plate XXVI.) . This i n t ra-uterine deformity in the now- 
born infant has been studied by Epstein. Such infants suffer from 
a troublesome coryza and cannot breathe freely through the nose. 
They present enlargemenl o( the liver and spleen, and there may 



452 



TEE SPECIFIC INFECTIOUS DISEASES. 



be a few copper-colored discolorations on the skin of the forehead 
and nose. The lips have a shiny, glossy appearance, and after a 
time may present distinct rhagades. Some days after birth there 
is a diffuse syphilitic eruption of papules or vesicopapules, with the 
so-called diffuse induration of the skin of the palms of the hand and 
soles of the feet, described by Hochsinger. Here and there discol- 
ored spots which were formerly mistaken for papules may be seen. 
The skin of the face may have a diffuse coppery color. Patches of 
discolored skin appear and become confluent, the coryza and rhagades 

Fig. 89. 




Hereditary syphilis ; rhagades and mucous patches of the lips. 



along the lips and at the angle of the mouth become more marked, and 
the rhagades bleed easily. 

In another class of cases the infant is born well nourished and has 
a good color. Within from two to four weeks a general eruption of 
papules and vesico-papules appears. Some of the vesico-papules are 
purulent, and after bursting dry up, leaving the surface covered with 
crusts on a copper-colored base. In these cases the manifestations 
on the mucous membranes, including coryza, mucous patches, and 
rhagades are also gradually developed (Fig. 89). If the above symp- 
toms are marked, we may find enlargement of the liver and spleen. 
I have seen the most marked signs of hereditary syphilis of the skin 
without the slightest enlargement of the liver or spleen. As a rule, 



SYPHILIS. 



453 



the arms will present papules, which may ulcerate at the points of 
contact with adjacent surfaces of skin. The typical condyloma lata 
is not frequent in early hereditary syphilis. The nates have a cop- 
pery shining color, are cracked in places and diffusely indurated 
(Hochsinger's induration). The trunk may present few symptoms. 
The bicipital glands are enlarged if the syphilitic exanthema is fully 
developed. The thighs show brownish, copper-colored patches. These 
patches give the skin a marbled appearance, which differs from that 
of the so-called healthy marbled skin in that the discolored areas are 
surrounded by normally colored skin, while in ordinary marbled skin 
the opposite condition obtains. On exposed areas, such as the knees, 



Fig. 90. 




Congenital syphilis ; circinate syphilide of the nose. 



nates, soles of the feet, and palms of the hands, the skin is diffusely 
indurated. 

In a detailed consideration of the lesions, those of the skin are 
the first to engage attention. The mosl common forms of eruption 
are the papular or the papulopustular form of syphilide. This may 
be combined with the macular form; in fact, ii is common to find in 
the same case all forms in various si ages o( development. 

The papules occur en the forehead, palmar surface of the hands 
and plantar surface of the feet, and on the nates ( Fig. 90), They 
show a distinct induration o\' the skin, are raised above the surface, 
and have a glossy, copper-colorea appearance. On the Dates or in the 
groin the papules may ulcerate; very rarely these form condylomata 



454 THE SPECIFIC INFECTIOUS DISEASES. 

lata in the early periods of congenital syphilis. The condyloma is 
a feature of the later period of this disease (Plate XXVII.). Ma- 
cules develop within the first three months of life, and from the sixth 
to the tenth week are associated with seborrhoea. Infants thus affected 
are born with a peculiar anaemia, in which the skin has a cadaveric 
hue. The macules appear on the forehead and face as copper-hued 
spots, which increase in number until the skin has a general marbled 
appearance (roseola syphilitica). They then fade, leaving the sur- 
face covered with brownish-red areas. These persist around the alas 
nasi and the forehead for a long time, giving the face a peculiar dirty- 
yellow spotted appearance. 

The diffuse syphilitic infiltration of the skin has been studied by 
Hochsinger. It is not the forerunner or the sequence of any papular 
eruption. It may be present as in one of my cases in the first week 
after birth, but appears in the third week in 50 per cent, of the cases, 
and reaches its height between the eighth and the tenth week. It 
first presents discolored areas on the palms and on the soles of the 
feet, on the nates, the calves of the legs, also on the cheeks and chin, 
where it forms rose-colored or copper-colored areas which coalesce. 
The soles and palms may appear diffusely red or bluish and glossy. 
The skin is diffusely thickened on the palms and soles and desqua- 
mates in lamella?. At the junction of the mucous membranes and 
skin fissures result on account of the thickening of the skin. The lips 
appear anaemic as a result of the infiltration of the mucous membrane, 
and are fissured. There are rhagades at the ala? nasi. The rhagades 
at the angles of the mouth are covered with a bluish-white pellicle, 
and the surrounding skin is copper-colored. There are swelling of 
the nasal mucous membrane with a thin, purulent discharge mixed 
with blood. The hair falls out on account of the infiltration of the 
scalp ; the scrotum is thickened and fissured from the same cause. 

The blood shows all stages of ana?mia, from the mildest to the 
grave pseudoleuksemic anaemia of von Jaksch, which some authors 
trace to syphilitic influences. 

The bones are affected with an osteochondritis, already described. 
This may appear in the first few weeks or at a much later period. It 
manifests itself by pain in moving the joints. The infant cries when 
handled. The mother notices that one or the other arm lies motionless 
at the side, and that every attempt to move it causes pain. Parrot 
described this condition as a pseudoparalysis. At the junction of the 
epiphysis and diaphysis at the lower end of the humerus or radius the 
bone may be swollen and painful. As a rule, the process affects the 
upper extremity on one side only, but in severe cases both the upper 
and lower extremities may be involved. In some cases this symptom 
may be present without a skin eruption. The other conditions which 



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SYPHILIS. 4 00 

simulate it are septic osteomyelitis involving the joints, scurvy, and 
severe rachitis. I have known instances in which prolonged obser- 
vation was necessary to clear up the case. 

A very characteristic but not common affection of the bones is 
the so-called dactylitis syphilitica (Fig. 91). This may appear as 
early as the fourth week, and may be associated with swelling of the 
epiphyses of the long bones. It consists of a fusiform swelling of 
the phalanges of one or more fingers. According to Taylor, this is 
primarily a gummatous infiltration of the skin, the periosteum, bone, 
and epiphyseal cartilage. In another form the periosteum and the 

Fig. 91. 




Congenital syphilis ; onychia of all the nails ; dactylitis of the phalanx of the index 
finger. Infant, four months of age. 

bone itself are the seat of the gummatous inflammation, the epiphysis 
and the joint becoming involved later in the process. In neglected 
cases, fistulas and destruction of the joint may result from necrosis 
of the epiphysis. The diagnosis of these forms of dactylitis from 
tuberculous spina ventosa is sometimes difficult, and often impossible 
without mercurial treatment. Cases of rachitis which involve the 
phalanges of all the fingers simulate very closely the above affection 
(see Rachitis). 

Syphilitic affection o( the liver gives do symptoms. Henoch 
records cases in which icterus was associated with enlargement of 



456 



THE SPECIFIC INFECTIOUS DISEASES. 



the organ. Hochsinger denies the occurrence during the nursing 
period of any authentic case of syphilis of the liver with icterus 
or ascites. 

Somma, Fischl, and Kohts have described symptoms of cerebral 
syphilis in infants that were subjects of hereditary syphilis. Con- 
vulsions, hydrocephalus, epilepsy, and paralyses have been traced to 
the presence of gummous meningitis or sclerosis. That such changes 
occur as a direct result of syphilis at so early a period is doubted by 
Henoch. I have not seen manifestations of cerebral syphilis in in- 
fants. Henoch is also inclined to include Mracek's cases of hemor- 
rhagic syphilis among the septic diseases of the newborn occurring in 
syphilitic infants. 

Antonelli in 1897 described changes in the fundus oculi of new- 
born syphilitic infants. These consisted of optic neuritis, retinitis 

Fig. 92. 




Hereditary syphilis ; gummata of the cranial bones. Child, eighteen months of age. 



vascularis, and retinochoroiditis. He believes these changes to be 
causative in the production of myopia and strabismus in such infants. 

Diagnosis. — The diagnosis of hereditary syphilis is not difficult in 
the vast majority of cases. If the fcetus is expelled dead it bears the 
marks of syphilitic infection, such as bullse and affections of the 
internal organs. Maceration alone is not indicative of syphilis. If 
the infant is born living, the evidences of syphilis are sometimes very 
few and equivocal. 

After a few months the diagnosis will sometimes be difficult ; the 
eruption will have disappeared, leaving only an anaemia of uncertain 
origin, with a few discolored areas about the nasolabial folds and 
around the temporal region. There is a suspicious dirty-looking 



SYPHILIS. 457 

seborrhoea of the supra-orbital region. A rebellions anal eczema or 
copper-colored intertrigo which, resists treatment should arouse sus- 
picion. Pustular papules are not pathognomonic even if combined 
with joint-affections. A case came under my notice in which an 
infant had a varicella-like eruption with a painful swelling of the 
right elbow-joint. A diagnosis of epiphysitis syphilitica had been 
made and the eruption had been mistaken for a syphilide. The color 
of the eruption was not that of a syphilide. Expectant treatment 
and immobility of the joint proved, after a few days, that the case 
was one of varicella with the joint-complication sometimes seen in 
that disease. 

In the diagnosis of late hereditary syphilis the symptomatology 
is of service. In cases with bone-lesions it is often very difficult to 
differentiate it from tuberculous affections (Fig. 93). An active 
course of treatment then becomes necessary, with a view to diagnosis. 
This is especially the case in arthropathies, and also in late forms of 
dactylitis. 

Fig. 93. 



■% 







Tuberculous affection of the bones of the hand simulating syphilitic disease. Child, 

sixteen months of age. 

Both in the hereditary and acquired forms of syphilis the Spiro- 
chetal are found in the blood at a very early period of the disease. 
In the acquired form it is found three weeks before the appearance 
of the roseola. In the congenital form it is found in the blood and 
internal organs and in the lymph which bathes the skin lesions, such 
as moist papules. Inasmuch as the recognition of Spirochete re- 
quires special apparatus and skill in staining, an expert must decide 
their presence. This is also the case with the Wassermann blood 
reaction. 

Prognosis. — The prognosis as to life depends upon several factors. 
A breast-fed infant is more likely to survive than a bottle-fed infant. 
The possibility o( complete restoration to the normal is slight. The 



458 THE SPECIFIC INFECTIOUS DISEASES. 

majority of infants bear the marks of the disease into adult life, 
even under very favorable conditions of treatment and environment, 
and develop late in life the so-called late symptoms of hereditary 
syphilis. Some infants while progressing favorably under treatment, 
die suddenly without apparent cause ; others remain stunted and deli- 
cate throughout childhood. Rachitis and its sequelae seem to be very 
prevalent among infants who are the subjects of hereditary syphilis. 
Treatment. — The treatment of congenital syphilis may be either 
internal, by inunctions or subcutaneous injections. I have found 
internal treatment to be the most satisfactory. The effects of mer- 
cury are not so injurious as is the case with the inunction methods. 
The drug employed was calomel in combination with the saccharated 
ferric carbonate (this was a favorite remedy with Widerhofer) : 

Calomel gr. £ (0.01). 

Ferri carb. sacc gr. iij (0.18). 

Ft. pulver. 

A powder of this size may be given every three hours or four times 
a day. Some authors (Baginsky) prefer the protoiodide of mercury, 
grain J to i (0.01 to 0.03). If there is intolerance to calomel, satis- 
factory results may be obtained by the use of Lustgarten's preparation 
of hydrarg. oxydulatum tannicum, in doses of grains ij to v (0.1 to 
0.3), repeated every three hours or four times daily. 

If the rhagades, especially those about the anus, bleed or heal 
slowly, they should be stimulated with a weak solution of silver 
nitrate. Calomel should be dusted upon condylomata lata three 
times daily. 

Baths of sublimate are recommended in severe cases of pemphigus, 
but it is not often necessary to resort to them. 

Infants in the nursing period do not bear inunctions well. I 
have seen several cases treated by this method which lost weight 
rapidly or died suddenly, and this has been the experience of others 
(Monti). The old method was to place grains viij to xv (0.5 to 1.0) 
of unguentum hydrarg. under the flannel abdominal binder daily, 
and allow it to be absorbed, or the same quantity of ointment was 
rubbed in daily on various parts of the body. 

Severe rhinitis is best treated by washing out the nasal passages 
once a day with a solution of corrosive sublimate (1:2000). The 
small glass syringe with a blunt soft-rubber nozzle is best for this 
purpose. After the syringing, unguentum iodoform is applied to the 
interior of the nose by means of a camel's hair pencil. 

How long should treatment be continued ? Xo matter what 
method of treatment is adopted, mercury should be administered until 
all discoloration of the skin has disappeared. To attain this result 



ACUTE ARTICULAR RHEUMATISM. 459 

will take a varying length of time in different cases. After the skin 
is clear and the anaemia has disappeared, it is well to cease the admin- 
istration of drugs and observe the patient for further symptoms. 
Sometimes a patient will be brought to the physician for the treat- 
ment of a rebellious intertrigo long after all signs of general syphilis 
have disappeared. Such an intertrigo may have a copper color, and 
may ulcerate, the ulcers having a peculiar lardaceous appearance. 
In these cases, even if all other signs of congenital syphilis are absent, 
the internal administration of mercury gives brilliant results. 

The treatment of late hereditary syphilis will depend much upon 
the nature of the therapeutic measures adopted earlier in life. In 
the majority of cases, the subjects being in later childhood or adoles- 
cence, it is well to begin treatment by a full inunction course, conducted 
on the same plan as with adult subjects with acquired syphilis. In 
addition, if gummatous affections of the bones are present, and if as 
in one of my cases visceral lesions, such as enlargement of the liver, 
have appeared, the patient is put upon gradually increasing doses of 
iodide of potassium. In one of my cases large doses of iodide of 
potassium failed to relieve the intense headache. This patient mar- 
ried, and after having a miscarriage gave birth under specific treat- 
ment to a healthy infant. The treatment of acquired syphilis does 
not differ from that of congenital or late hereditary syphilis. 

ACUTE ARTICULAR RHEUMATISM. 

{Polyarthritis Rheumatica; Rheumatic Fever.) 

Etiology. — Although acute articular rheumatism is still regarded 
by some authors as a constitutional disease caused by disturbances of 
nutrition which result in local manifestations, the general tendency 
is to regard it as an acute, infectious disease. The infectious agent, 
whether bacterial or toxic, attack the serous cavities, such as those 
of the joints, the pericardium and endocardium, and the pleura. 
The resemblance of rheumatism, especially in children, to the infec- 
tions is sufficiently great to warrant a serious consideration of this 
theory. Thus in septic endocarditis in children, as in the adult, there 
are symptoms of pain in the joints. Chronic cases of endocarditis of 
a rheumatic nature in course of relapse occasionally take a septic 
course. There are found circulating in the blood streptococci of dif- 
ferent grades of virulency. Certain diseases, such as erythema nodo- 
sum and peliosis rheumatica, in which the joint-symptoms are marked. 
are regarded as being caused by infection of a bacterial nature. 
I have seen such a ease of peliosis. In other diseases, such as 
scarlet fever, measles, and varicella, there are joint-affections which 
are recognized (o be o( an infectious nature, Lastly, both American 



460 TEE SPECIFIC INFECTIOUS DISEASES. 

(Packard) and English writers have called attention to the well- 
observed clinical fact that there are forms of rheumatism and endo- 
carditis which follow attacks of tonsillitis of the lacunar type or 
accompany them. It is true that the infectious agent, whether bac- 
terial or toxic (Chvostek), is still to be discovered. Time may show 
that not one, but a variety of micro-organisms are capable of causing 
rheumatism of the acute articular type in a susceptible organism. 
Streptococci, the so-called Streptococcus or Diplococcus rheumatica, 
have been found in the exudate of the joints (Hlava) and in the 
blood. Staphylococcus aureus, citreus, and albus have been found 
in the blood (Gutmann, Tizzoni, Bouchard). The pneumococci of 
Frankel and the Diplococcus tenuis have been found in the joints 
(Leyden). Singer has found similar micro-organisms in the urine. 

Heredity is among the predisposing causes. Children whose 
parents are markedly rheumatic, may suffer severely from the affec- 
tion. Cold and exposure certainly predispose to the disease or pre- 
cipitate attacks. The disease is common in countries such as England 
and America, in which climatic influences are favorable to its devel- 
opment, and is especially prevalent in the moist and cold seasons of 
the year. 

Age. — Rheumatism has been described as occurring in early in- 
fancy (Jacobi) . I have published a case in an infant of nine months. 
Rauchfus, Chapin, and others have also described cases in infants. 
These cases were collected by Miller, who, with his own case (nine 
m®nths), found 19 authentic cases in the literature in nursing infants. 
Although rare in infancy, rheumatism is not uncommon in children 
from the fifth to the tenth year. The majority of the cases of rheu- 
matism occur between the tenth and the twentieth year. 

Sex. — Among adults, males are more subject to the disease. In 
children, however, although certain observers contend that it is more 
prevalent among girls, other statistics show that it has the same fre- 
quency of occurrence in the sexes. 

Symptoms. — Certain peculiarities, pointed out by Jacobi, seem to 
differentiate acute articular rheumatism of infants and children from 
the same affection in adults. But few joints are attacked. The pain 
and swelling are generally not very marked. The redness of the 
joints is slight or altogether absent. The temperature is rarely high. 
The smaller joints, such as the maxilla, sternoclavicular articulation, 
and those of the vertebra?, are rarely attacked. The larger ones, such 
as the ankle-, knee-, and wrist-joints, are most commonly affected. 

Cardiac complication is the rule. As Jacobi has pointed out, 
endocarditis is sometimes the first manifestation of the disease. In 
many cases obscure pains in the joints of months' duration precede 
the development of a murmur. 



ACUTE ARTICULAR RHEUMATISM. 401 

Clinical Types. — In infants and young children the first signs are 
swelling and pain in the affected joints. The infant in the nursing 
period cries, has fever, and is restless. On investigation it is found 
that the patient favors one extremity, and shrieks with pain when it 
is touched. Children of two and one-half years or more refuse to 
walk, and will complain of the affected joint, ankle, or knee. There 
will be fever and constitutional symptoms. The ankle, and in some 
cases the smaller joints of the foot are swollen. One of the knees, 
the wrist, and elbow may also be swollen, red, and painful. The 
fever rarely rises above 103° or 103.5° F. (39.4° C). In other 
cases there are fever and restlessness, and sometimes pains of an 
indefinite character in the joints. A history of pain may be elicited 
by careful questioning and examination. 

Monarticular pain is very characteristic of the form of rheuma- 
tism seen in children. Still and Barlow call attention to the fact that 
a pain in the hip may be mistaken for tuberculous hip-disease, when 
in truth it is rheumatic. I have seen these cases, but have been 
impressed with the fact that in infants scurvy also begins in this way. 

The physician may find an angina, slight or marked; the heart 
may show signs of endocarditis of an acute type. There are pains in 
the joints but no true rheumatic swellings. The pains more closely 
resemble those in uncomplicated angina tonsillaris. In older chil- 
dren, a history of joint-pains with endocarditis may be obtained. In 
other cases, the pains in various joints are the only symptoms. There 
is no swelling or redness, and no endocarditis. Some cases have no 
fever. The classical cases, however, closely resemble those of the 
affection as seen in the adult. There may be premonitory symptoms, 
but as a rule the patient is brought to the physician with the enlarge- 
ment of the joints fully developed. After the joints have become 
enlarged they may return to the normal in a few days, but may again 
be the seat of pain and swelling. The swelling in the joints of chil- 
dren does not persist as long as in the adult subject, and as a rule 
children are less disabled. In many cases there are gastric pains. 
The children do not show any greater tendency to perspire than adults. 

Endocarditis. — Endocarditis is usually a complication of rheu- 
matism in children. Its absence is rare. Only 2 of 15 of my hos- 
pital cases were free from cardiac complication. The most common 
cardiac lesion is found at the mitral valve and is manifested by a 
single systolic murmur at the apex. Three of the cases showed the 
presence of a double mitral murmur. Endocarditis sometimes does 
not reveal its presence by any symptoms, and is only discovered on 
a careful examination. In many of the cases there is also a peri- 
cardial friction first heard at the 1 apex or base 1 of the heart. The 
pericardial friction is more common in children than is generally 



462 TEE SPECIFIC INFECTIOUS DISEASES. 

supposed. The pericarditis frequently remains in the dry friction 
stage, and does not advance to effusion. Pleuritis and bronchopneu- 
monia are among the less common manifestations. The endocarditis 
sometimes occasions pain and distress. The presence of endocarditis 
as an acute affection in first attacks of rheumatism has been dilated 
upon in the section on Endocarditis. 

Chorea. — The relationship of chorea and rheumatism has been 
discussed. I have seen a child of two and one-half years born of 
a rheumatic mother, develop first rheumatism and endocarditis, and, 
within a few days, marked chorea. On the other hand, in many cases 
of chorea, there is neither endocarditis nor a history of rheumatism 
in children or parents. The statistics of chorea in hospital service 
show a greater frequency (39 per cent.) of cardiac disease with or 
without a history of rheumatism than the ambulatory cases. This is 
explained by the fact that only the severer cases of chorea come to 
the hospital. 

Prognosis. — The prognosis of acute articular rheumatism in in- 
fancy is good as to life. On the other hand, it is a disease which is 
likely to recur and to be complicated by endocarditis. The latter fact 
should cause the physician to reserve any definite prognosis until the 
course of the disease has been carefully studied. The prognosis of 
rheumatic endocarditis can never be definitely made. All depends 
on the amount of damage done to the valves and the frequency of the 
recurring attacks. 

Treatment. — The treatment of acute articular rheumatism in chil- 
dren is not essentially different from that followed in the adult. Sali- 
cylic acid, bicarbonate of sodium, salicylate of sodium, aspirin, and 
oil of wintergreen are the remedies usually given. 

The bowels should be kept open with an alkaline cathartic. The 
Carlsbad salt or Rochelle salt given daily is best adapted for this 
purpose. The patient is put on a milk diet ; fruit juices are allowed. 
The patient is kept in bed. The affected joints, if painful, are either 
immobilized or wrapped in cotton. Some prefer to paint the joints 
with a solution of oil of wintergreen, and then wrap them in cotton. 
Salicylate of sodium is given internally in doses of grains ij to v 
(0.12 to 0.3) according to the age. A grain of salicylate of soda is 
given for every year of the age combined with twice the quantity of 
bicarbonate of soda. Young children are given a dose every three 
hours. Older children are given doses of grains vij to x (0.5 to 0.6). 
The effect is watched. Salol or salophen may be given. The sali- 
cylates sometimes not only act as irritants to the stomach, but also 
have no appreciable effect on the course of the disease. Aspirin has 
in my hands been useful in cases in which the salicylates were inef- 
fective. In some cases I give bicarbonate of sodium in increasing 



ACUTE ARTICULAR RHEUMATISM. 46:i 

doses until the urine becomes alkaline. Endocarditis is treated on 
the principles laid down in the section on that disease. While under 
treatment the patient is given alkaline waters. During convales- 
cence the various preparations of iron are of great value. The prepa- 
rations of lithium are useful in cases in which there are indefinite 
pains in the joints. The carbonate is given in doses of grain j (0.06) 
three times daily. It is given in capsule to older children after 
meals. 

The method of treating rheumatic subjects by the occasional 
administration of salol or salicylates for months has been suggested. 
The salicylates upset the stomach, so that the alkalies alone are avail- 
able. The patient is given grains v (0.3) of sodium bicarbonate 
twice daily. Yichy water is used regularly. In some cases the 
tablets of vichy taken once or twice daily are of great value. 

Rheumatoid Arthritis (Arthritis Deformans; Still's Disease). — 
This affection should be sharply differentiated from all forms of 
chronic or subacute articular inflammation. Charcot and Weil have 
described this form of arthritis in children. The cases are not com- 
mon. After the publication of my case, two others were described 
in the American literature, one of the descriptions being given by 
Manges. Cases of arthritis deformans or rheumatoid arthritis in 
children are referred to by Osier (4 cases) and Henoch (5 cases). 

Symptoms. — The onset of the disease is either sudden after an 
exposure to cold and wet, or slow. In one form, after an onset of 
chills and fever, soreness and pain in several joints appear. The 
child is at first able to be about, but, as the joints become more and 
more affected, complete disability results. The pain in the joints 
becomes so marked as to interfere with sleep. After a few months 
the patients may be unable to walk. In some cases the enlargements 
and pain begin in the lower extremities and gradually involve other 
joints. In others the onset is slow. The joints of the upper and 
lower extremities gradually become painful, and after repeated attacks 
remain swollen and limited as to motion. The ends of the bones are 
enlarged and there is effusion in some joints. With the progressive 
involvement of the joints there is atrophy of the muscles, as in the 
adult form of the disease. When the disease is fully developed the 
condition is pitiable. In my case almost every joint in the body, 
including those of the cervical vertebrae, Avas involved; the temporo- 
maxillary articulation, the shoulder, the elbow, the small finger-joints, 
the hips, knees, ankles, and toes, were all att'eetod. The patient slept 
in a semi-upright posture, and had to be carried from place to place. 
There was very limited and painful motion in all the affected joints 
(Fig. 94). 

Brabazon found that of 100 cases of this affection, onl? 3 oei 



464 



TEE SPECIFIC INFECTIOUS DISEASES. 



cent, occurred between the ages of five and fifteen years. Two 
theories have been advanced to explain this joint-affection; one, that 
of Charcot and Weil, is the neurotic theory, which is plausible because 
of the bilateral nature of the affection, the atrophy of the muscles 
around the joints, the changes in the skin which becomes in time 
tense and shining, and the enlargement of the ends of the bones which 
enter into the formation of the joints. The infectious theory is sup- 
ported by the fact that there is in many cases a diurnal fluctuation of 
temperature of a degree or a fraction of a degree above the normal. 



Fig. 94. 




Rheumatoid arthritis in a child seven years old. Deformity of all the joints with 
fixation. Child forced to assume this attitude awake and in sleep. 



The lymph-nodes are enlarged ; the liver and spleen are also enlarged 
in some cases (see Still's Disease) . The heart is not usually involved. 

Prognosis. — The prognosis as to life is good. 

Treatment. — Treatment by massage, warm baths, and patient 
manipulation of the joints under anaesthesia, may effect slight im- 
provement. In my case improvement was noted after a year of con- 
stant treatment. Iodide of potassium is the only drug which relieves 



ACUTE ARTICULAR RHEUMATISM. 



465 



the pain. In some cases it exerts a favorable influence upon the 
course of the disease. 

Still's Disease. — This form of rheumatoid arthritis probably bo- 
longs in the same class as that just discussed. It is described by 
Still and is thought by him to be essentially peculiar in its symptom- 
atology to children. 

Etiology. — It is apparently an acute infection of obscure etiology, 
rheumatoid in its nature, affecting for the most part the larger joints, 
especially the elbows, wrists, knees, ankles, and in some cases the 
smaller joints, especially of the fingers. 

Fig. 95. 








(m 



<&k\ 




Still's Disease in boy of eight years. Large and small joints affected, 
vertebrae ; enlarged lymph nodes, liver and spleen. 



also cervical 



Symptoms. — It is accompanied by periods of pyrexia and hyper- 
pyrexia and what is mainly characteristic, enlargement of the lymph- 
nodes, liver, and in most cases of the spleen. The joints of the cer- 
vical vertebrae were involved in the cases described by Still. There 
was no clinical involvement of the heart, though postmortem there 
was adherent pericardium in some eases and mitral involvement in 
another (Fig. 95). 

The condition in half the eases began before the second dentition, 
girls being more often affected than boys. The enlargement of the 

30 



466 THE SPECIFIC INFECTIOUS DISEASES. 

joints is fusiform without redness but with varying amount of ten- 
derness. There may be limitation of pain and in three of my cases 
there was limitation of motion. The lymph-nodes affected are the 
axillary, epitrochlear, and posterior cervical. In some cases the 
spleen was not enlarged. Still wishes to place these cases in a dis- 
tinct class on account of the enlarged lymph-nodes, spleen, and liver. 
I have had four cases of this form of rheumatoid arthritis, one of 
which made a very excellent recovery. 

Treatment. — The treatment is ihe same as in rheumatoid arthritis. 

Other Forms of So-called Rheumatism. — (Rheumatoid Affec- 
tions). — There are three forms of joint-affection which it is not yet 
advisable to class with true articular rheumatism, but which are con- 
stantly and incorrectly called rheumatic. 

Gonorrheal Form. — The gonorrheal form of rheumatoid affection 
is seen in infants and children who suffer from gonorrheal vulvo- 
vaginitis or urethritis (Hartley, Koplik, Moncorvo). It may be 
monarticular or many joints may be affected. It is not, as a rule, 
combined with endocarditis. I know of no such case in the literature. 

Peliosis. — Cases of so-called peliosis rheumatica closely resemble 
acute articular rheumatism. I have seen several in older children. 
In one there were for weeks repeated painful swellings of the joints, 
with purpuric eruption about them. The gastric pains and critical 
sweats so often seen in rheumatism were present. These cases rarely 
present a temperature above 100.5° F. (38° C). They show no 
cardiac lesion. 

Tonsillitis with Joint-pains and Endocarditis.. — Under the proper 
heading I have referred to cases of tonsillitis with indefinite pains in 
the joints and complicated with endocarditis. 

Erythema Nodosum. — I have seen many cases of erythema nodosum 
in children. In all, the typical painful swellings on the anterior 
aspect of the tibia were present. There were also joint-pains, but in 
only 5 cases could I establish the presence of an endocardial murmur. 
I am therefore not willing to accept without reserve the contention of 
French authors that endocarditis is frequent in these cases. 

Subcutaneous Rheumatic Nodules. — The so-called subcutaneous 
rheumatic nodules are seen in children less frequently in this country 
than in England. They occur in endocarditis, and were present in 
20 per cent, of Court's cases (Donkin). They may be present in the 
absence of fever or in the febrile stage of rheumatism. They may be 
minute or of the size of an almond. They appear in crops, and may 
alternately appear and disappear for weeks. The nodules occur 
about the joints, elbows, knees, patella, over the vertebra? and scapula, 
and are freely movable under the skin which is not discolored. I 
have seen them in a case of rheumatoid arthritis, and also in one of 
peliosis rheumatica. 



ACUTE AETICULAB EHEUMATISM. 40/ 

Muscular Rheumatism.. — Muscular rheumatism is rare in infancy 
and childhood. Henoch describes cases of contracture of the muscles 
of the neck and of the nape of the neck. Among such contractures 
are forms of torticollis which are said to have a rheumatic origin. I 
have met many cases of torticollis in which with the contracture there 
was swelling of the cervical lymph-nodes. In such cases I have found 
eczematous affections of the scalp. It is possible that there was an 
acute infectious neuritis or myositis. There may, however, be cases 
resting on a purely rheumatic basis. All forms of torticollis due to 
hsematoma of the sternomastoid muscles or to cervical bone disease, 
glandular disease, or neuritis should be excluded before a definite con- 
clusion is reached. Henoch also refers to contractures of the abduc- 
tors of the thigh which are of rheumatic origin. I have never seen 
cases of the kind. 



SECTION VI. 

DISEASES OF THE MOUTH, TONGUE AND 
(ESOPHAGUS. 

DISEASES OF THE MOUTH. 

Physiological Facts. — The mouth of the infant up to about the 
eighth month is devoid of teeth, and thus nature indicates that the 
infant is not prepared to masticate solid food. The salivary glands 
show very little activity in the first three months of infancy, the secre- 
tion of saliva at this time being small in quantity. 

In the newborn, before it has partaken of food, the reaction of 
the secretions of the mouth is neutral or slightly alkaline. Though 
an amylolytic ferment is present in the secretion of the parotid gland 
in the first days after birth (Zweifel), the function of this ferment is 
as yet a matter of speculation, inasmuch as the food of the newborn 
breast-fed infant contains nothing in which the action of such a fer- 
ment might be manifest. 

Of interest is the act of nursing, which in the infant takes the 
place of the process of mastication. 

Physiology of the Act of Nursing. — If an attempt is made to feed 
the newborn infant with fluids, either from the spoon or pipette, there 
follows an abortive attempt at swallowing, accompanied by choking; 
it thus requires some skill and practice to induce the newborn infant 
to swallow fin ids administered in this way. NTot so with the breast. 
The newborn child instinctly takes the nipple of the breast, and nurses 
without previous education or preparation. The act of nursing, there- 
fore, is purely reflex. 

Thompson has described the so-called lip reflex. If the infant at 
rest or sleeping is gently tapped or touched on the upper or lower 
lip in the neighborhood of the commissure, there follows a reflex 
movement of the lips. If they have been separated, they close 
and form themselves into a pouting position; in other words, they 
purse themselves as if in readiness to take something into the mouth. 
The breast-nipple, therefore, performs a function for the infant 
similar to that of the finger in producing this so-called reflex of the 
lip. The nipple once having touched the lips of the infant is re- 
ceived by the pursed lips into a funnel-shaped opening, and the lips 
grasp the nipple and some of the adjacent skin. It is received be- 
tween the hard palate above and the superior surface of the tongue 

468 



DISEASES OF TEE MOUTH. 469 

below. The lower jaw aids in making the contact between the lips 
and the nipple complete. The act of nursing itself is the estab- 
lishment, first, of a negative pressure, caused by the act of suction, 
equal to 0.5 to 0.9 centimetres of mercury. This alone would not 
determine the flow of milk into the mouth of the nursling were it 
not for the muscular pressure from below of the lower jaw. The 
combined force of the negative pressure produced by the act of suction 
and the muscular pressure from below on the nipple as it joins the 
breast is equal to 4 centimetres of mercury. This has been shown 
experimentally to be quite sufficient to determine a steady flow of 
milk from the breast into the mouth of the nursling. It takes from 
three to four acts of suction and muscular pressure to fill the mouth 
sufficiently to cause one act of swallowing on the part of the infant. 

Landmarks of the Normal Mouth. — There are certain localities 
of the mucous membrane of the mouth which are especially liable to 
aphthse or ulceration. Among these we must mention the mucous 
membrane over the hamular process of the palate bone, where it is 
normally paler than the surrounding tissue. This pale area on either 
side of the median line may be the seat of the so-called Bednar's 
aphthae. Midway in the raphe of the hard palate in most newborn 
infants are seen one or two, at most three, yellowish- white, sago-like 
objects; these are called Epstein's pearls, because they were first 
described by this clinician. They are collections of epithelial cells, 
the remains of embryonal formations. These epithelial pearls are 
quite susceptible to traumatism, and if injured in any way become 
the seat of ulceration. Laterally on the hard palate over the alveolar 
process, above and below the mucous membrane is thin and has a 
white reflex. Any slight traumatism in this locality may cause ulcer- 
ation. The tonsils of the newborn infant are scarcely visible. The 
posterior pharyngeal wall is glossy, of a bluish-pink color. On closer 
examination of the fauces of infants, bodies resembling drops of dew 
or vesicles are seen just in front of the tonsil. These are collections 
of lymphoid tissue, and are normal to the infant's mouth. They 
may become inflamed and form aphthous ulcerations, and when so 
inflamed are called herpes of the tonsil. There are also visible on the 
soft palate of children minute miliary, transparent bodies resembling 
vesicles, which are likely to enlarge in any disease affecting the 
mucous membrane of the mouth, as in the exanthemata. These also 
are aggregations of lymphoid tissue. 

Bacteria of the Mouth. — The bacterial flora of the mouth of the 
infant have been the subject of investigation by Lewkowicz. Only 
the leading flora can be mentioned here: the pneumococcus, which is 
constantly present but not pathogenic; the streptococcus, in long 
chains similar to the pyogenic variety but not pathogenic; the Strep- 
tococcus salivse oi' Veillon, the Streptococcus aggregatus o( Seitz, the 



470 DISEASES OF THE MOUTH. 

Staphylococcus pyogenes albus, the Streptococcus intestinalis or en- 
teritidis of Escherich, the Micrococcus candidans (Fliigge), the Ba- 
cillus acidiphilus of Moro, the most constant and frequent of the 
bacillary group ; and the pseudodiphtheria bacillus. There are also, 
strange to say, anaerobic bacteria to be found in the mouth of infants, 
the most important being the Bacillus bifidus communis of Tissier. 
In all there are 23 varieties of bacteria normal to the buccal cavity of 
nursing infants. 

Normal Dentition. — The teeth, both temporary and permanent, 
are contained in the so-called tooth-sacs, which are situated in the 
alveolar process of the upper and the body of the lower jaw. The 
formation of these sacs begins in the sixth month of foetal life, by a 
coalescence of the folds and papillae formed in the jaw. There are 
twenty temporary teeth, and the sacs of the permanent teeth are 
situated against the posterior wall of the sacs of the temporary teeth, 
and probably communicate with them. As a result of the growth 
of the roots of the teeth, the temporary teeth are pushed through the 
cartilaginous border of the jaw and the mucous membrane, and thus 
appear externally. 

Temporary or Milk Teeth. — The eruption of the temporary or milk 
teeth begins about the sixth or seventh month with the lower incisors, 
and ends about the third year with the posterior molars. The erup- 
tion of the teeth, even in normal infants, varies within wide limits, 
some infants being precocious and others late in this process, without 
necessarily showing any signs of bone disease, such as rachitis. We 
might group the eruption of the milk teeth into five groups as follows : 
The first would include the two lower incisors, which erupt at from 
the seventh to the ninth month. There is then an interval of from 
three to nine weeks, when the second group, consisting of the four 
upper incisors, appears from the eighth to the tenth month. After 
this there is an interval of from six to twelve weeks, when the third 
group appears. This consists of the first molars and two lower lateral 
incisors, which erupt from the twelfth to the fifteenth month. An 
interval of three months then occurs, and the canines appear in the 
fourth group from the eighteenth to the twenty-fourth month. There 
is an interval of two months, and the four second molars appear. At 
the fifth or sixth year the third molar appears, and then the second 
dentition begins. 

As exceptions to the above order, we may have the two upper 
lateral incisors delayed until the sixteenth month; the two upper 
incisors and the four posterior molars may be delayed as late as the 
thirty-sixth month. At the twelfth month an infant should have the 
four upper and two lower central incisors, with two lower lateral 
incisors coming. The lower incisors may not appear until the eighth 
or ninth month, and then be followed rapidly by others. I have seen 



DISEASES OF THE MOUTH. All 

several infants with one or two incisors at birth; they, as a rule, were 
imperfectly formed and resembled canines. These prematurely 
erupted teeth should be extracted if they interfere with nursing and 
lacerate the nipple of the breast. In some cases the upper incisors 
may appear first, and rarely canines may appear before molars. 

Permanent Teethe — The second dentition begins at the end of the 
sixth or seventh year with the eruption of the first molar behind the 
second temporary molar. The milk teeth at this time loosen because 
their arteries become obliterated, the nerves disappear, the alveolar 
sacs enlarge, and they fall out or may become carious. The perma- 
nent teeth appear in the second dentition, as has been said, very much 
in the order that the milk teeth appear — the central incisors about 
the eighth year, the lateral incisors at the ninth year, and the last 
molars from the eighteenth to the twentieth year, or even later. 

Abnormal Dentition. — Rachitis. — Kachitis is a common cause of 
delayed dentition. Artificially-fed infants are backward in cutting 
their first incisors. It is common to see bottle-fed infants cutting the 
lower anterior incisors at the ninth month. The infants may be in 
other respects normal. Rachitis affects the teeth of the first denti- 
tion mostly, but may influence the form and structure of the teeth of 
the second dentition. The teeth of the first dentition in rachitis are 
easily broken and are unnaturally white. In many cases the anterior 
incisors show an incurvation on the lower cutting edge, which is often 
mistaken for Hutchinson's deformity. The first teeth in rachitis are 
easily eroded. It is not uncommon to see a rachitic infant with its 
whole dental system in process of decay. The permanent teeth pre- 
sent abnormalities in inordinate size and longitudinal furrows. 

Syphilis. — The permanent teeth are affected by syphilis in a char- 
acteristic fashion. 

Fig. 96. 




Hutchinson's teeth in a boy. twelve years of aye. 

Hutchinson s 2VW//.— Hutchinson's teeth are so called because 
they were first described by Jonathan Hutchinson. The} arc the 
only teeth of the permanent se1 which are pathognomonic of congen- 
ital or very early acquired syphilis (infancy) (Fig, 96), In a large 



472 



DISEASES OF THE MOUTH. 



experience with syphilis in infancy and childhood I have seen hut 
few perfect examples of these teeth. The teeth presenting the de- 
formity are the central upper incisors of the permanent set, and these 
only. " These teeth show a central single, rather broad notch." In 
this notch the dentine, lightly covered by enamel, is exposed. It is 



Fig. 97. 




Fig. 98. 



Permanent teeth deformed through stomatitis in early childhood, resembling Hutchin- 
son's teeth. Female child, nine years of age. 

seen as a ridge in the incurvation. The teeth are shorter and broader 
than is natural, and almost always have their angles sloped off. They 
are thus narrower at their cutting edge than higher up. They are 
seldom or never of good color, and frequently are not placed quite 
straight, but slope either toward or away from each other. Teeth 
which are the seat of erosion may resemble Hutchinson's teeth (Fig. 

97). Fournier has described teeth in the 
temporary set which closely resembled Hutch- 
inson's teeth. I have met an exquisite ex- 
ample of such teeth in an infant sixteen 
months old, the subject of syphilis (Fig. 98). 
In syphilitic subjects we find the follow- 
ing deformities in the permanent teeth. These 
peculiarities are not characteristic of syphilis 
alone, but are found in those who are not 
syphilitic, but have suffered from stomatitis or dyscrasia of some kind. 
The changes are bilateral and symmetrical. 

Dental Erosions. — The most important erosions, such as those of 
Hutchinson just described, affect the central incisors. Other erosions 
give the teeth an incurvated appearance on their cutting edge. In 
this incurvation is seen a supernumerary crown ribbed in a longitu- 




Central upper incisors of 
the first dentition resem- 
bling Hutchinson's teeth. 
Syphilis of the flat and 
long bones. Child, sixteen 
months of age. 



DISEASES OF THE MOUTH. 



473 



dinal direction (Figs. 99 and 100). The whole may be mistaken for 
Hutchinson's deformity. They result from malnutrition or stoma- 
titis with faulty formation of dentine and enamel deposit in the 
eruptive period of the permanent teeth. The first molars show very 
characteristic deformities, which Fournier places next in importance 
to those of the Hutchinson teeth, but does not regard as pathog- 
nomonic of syphilis, although they are met in syphilitic subjects. 
This deformity of the first molars is shown in Fig. 101, taken from a 



Fig. 99. 



Fig. 100. 




central incisors, with erosions 
not syphilitic. 




Lower incisors, with erosions not syphilitic. 
Child, eight years of age. 



child who showed other erosions, but gave no history of syphilis. I 
have seen these erosions very well marked in children who had posi- 
tive syphilitic manifestations. The top of the crown is constricted, 
and there appears to be a double crown. Erosions are also seen in 
the canine teeth. 

Microdontism. — The teeth are quite small, but if cared for remain 
perfect in shape, pearly and transparent. They are seen in children 



Fig. 101. 



Fig. 102. 




Erosion of molars, not nec- 
essarily syphilitic. 




Molar tooth, showing erosion at 
crown. Boy, twelve years of ace ; 
same patient as with Hutchinson's 
teeth. 



whose parents may have suffered from syphilis. The children may 
also have obstinate eczema of the aims (parasyphilitis . Micro- 
dontism may occur also as a result of any non-syphilitic dyscrasia. 

Denial Infantilism. — Dental infantilism, described by Founder, 
occurs in children who are syphilitic. Small teeth presenting ero- 
sions are interspersed among teeth which are normal in size and shape. 

Amorphism. — Amorphism, or the tendency of a tooth, such as the 



474 DISEASES OF TEE MOUTH. 

incisor, to take the shape of a canine, has been noted by Fournier. I 
have also met with cases of this deformity in congenitally syphilitic 
children. It is seen in children who have had syphilis, but may be 
met with in those who have no such history. 

Children, subjects of syphilis, do not always present deformities 
of the teeth. In a girl of fourteen years, who gave a history of infan- 
tile syphilis, and who had late manifestations, such as gummata in 
almost all the bones, joint-affections, and gummata of the liver, the 
teeth, both upper and lower, were normal and of great beauty. 

Pathology of Dentition. — The period of infantile dentition is 
one of great physiological activity and growth. The organism is 
forming at this time. The nervous system is in a condition of insta- 
bility. The gut is exposed to and is very susceptible to all varieties 
of infections. During this period the infant or child suffers from a 
number of diseases and exhibits a variety of symptoms which in 
former times were difficult of interpretation. With advancing knowl- 
edge and the possibility of making more accurate diagnoses than were 
formerly feasible, the diseases incidental to dentition have become 
more a matter of speculation. There are clinicians of note who still 
believe that irritation of the trigeminal branches by an erupting tooth 
may cause reflex eclampsia. It is difficult, and not necessary, to 
pass here on the status of that section of infantile pathology which 
treats of the disorders incident to dentition. In the presence of mys- 
tifying symptoms the physician should make a very careful examina- 
tion, in order to make a diagnosis. Clinical observation of a case 
for a few days, and accurate registration of the pulse, respiration, 
and temperature every three hours, may show that the diagnosis of 
dentition must give way to something more tangible. 

Should the Gums be Incised? — I have often found the tooth- 
sacs to be swollen and the seat of painful distention just before the 
eruption of the teeth. In one case the tooth-sac was distended by a 
hemorrhage into its cavity. Many cases of tense tooth-sacs or hemor- 
rhage into such tooth-sacs are evidences of scurvy or disturbed nutri- 
tion. Under these conditions I have not yielded to the entreaties 
of the mother to lance the gums. I have seen no ill effects result 
from this laissez faire method. Very painful ulcerations result from 
friction, and uncontrollable hemorrhage may follow incision. In 
cases in which the sacs are distended, the functions of the stomach and 
gut should be kept normal, in order that complications may not be 
added to existing conditions. In rare cases I have seen suppuration 
in the tooth-sac, and have incised. In cases of scurvy in which the 
tooth-sacs are distended and bluish in appearance, treatment of the 
scurvy improves this condition. 

Ulcerations or Erosions of the Angles of the Mouth (Fr., Per- 



DISEASES OF THE MOUTH. 475 

Uche; Ger. (Faule EcJcen) Epstein). — Definition. — This is a form 
of non-specific ulceration or rhagade occurring at the corners of the 
mouth, affecting the vermilion border of the mucous membrane. 

Occurrence. — This affection is seen in children who present other 
signs of malnutrition, such as scrofulosis or lymphatism. They are 
anaemic, suffer from nasopharyngeal catarrh or skin eruptions, and 
live in unhygienic surroundings. The disease is seen in children 
under two years of age, and mostly beyond that period. The disease 
is confined to the corners of the mouth, and may be strictly limited 
to them, though the author has often seen it combined with erosions 
of the alas nasi. 

Symptoms. — These erosions, fissures, or rhagades consist of lineal 
ulcers of the corners of the mouth, which may have a red base and 
elevated borders, or the base and borders may have a bluish tinge, 
resembling mucous patches. In these children the question of diag- 
nosis of these rhagades from those due to syphilis is constantly arising. 
The induration of the base of the ulcer which is present in syphilis 
is absent in the non-specific rhagade. The surface of the ulcer has 
a more lardaceous appearance in syphilis as a rule, the lips are in- 
volved, and there are mucous patches elsewhere. 

The affection which we are describing is found isolated and lim- 
ited to the corners of the mouth. The borders of the rhagade may 
be surrounded by minute pustules. The rhagade is symmetrical, 
involving both sides of the mouth. It is not painful unless the mouth 
is put on the stretch or acid substances applied to the base of the ulcer. 
In other cases the borders of the rhagades are raised and indurated. 
I have seen a large number of these rhagades ; some, at least, so closely 
resembling a syphilitic lesion as always to warrant a careful exclusion 
in each case of this affection. 

Diagnosis. — The diagnosis offers no difficulty, though it is an 
affection which rarely comes to the physician to be treated as an 
isolated disease, and is generally met in combination with other dis- 
eases. I have seen it in children suffering from typhoid fever. The 
disease may be mistaken for diphtheritic infection, inasmuch as in 
some cases the base of the rhagade is covered by a pseudomembranous, 
whitish deposit. The culture tube will decide the true nature of the 
lesion in such cases. 

Course. — The duration of the disease extends over a period o( two 
or three weeks; if untreated, it usually becomes chronic. 1 have suc- 
ceeded in curing these rhagades by touching them once daily with a 
10 per cent, solution of nitrate of silver, and then applying th e oint- 
ment of red oxide of mercury. Another remedy is the application oi 
a solution of corrosive sublimate (1 : 2000). 

Bednar's Aphthae. — Bednar's aphthae, named after the distin- 



476 



DISEASES OF THE MOUTH. 



guished Viennese pediatrist who first described them, are two sym- 
metrical ulcerations over the hamular process of the palate bone, seen 
in the newly born or very young infant (Fig. 103). They are the 
result of traumatism. They are seen in infants in whom the mouth 
has been too scrupulously cleansed. In these cases the finger of the 
nurse in the act of cleaning impinges against the hamular process of 
the palate bone and abrades the epithelium. Any bacteria which 
may be present in the mouth or on the finger thus gain foothold and 
ulceration results. Epstein has shown that in the newly born infant 
such ulcers may be the starting-point of a general sepsis. 

Fig. 103. 




View of the hard and soft palate. Lateral ulcerations — so-called Bednar's aphthae. 



The infant may refuse to nurse, or if it does attempt to do so, 
the pain caused by the act of suckling causes it to desist. There may 
be intestinal disturbance, manifested by greenish stools, and there 
may be infection of the gut by the bacterial flora of the ulceration. 

Treatment. — The ulcer should neither be washed nor traumatized. 
The rest of the mouth and tongue should be washed gently twice daily 
with a saturated aqueous solution of boric acid. The ulcers should 
be touched once or twice a day with a ten per cent, solution of silver 
nitrate applied with a small piece of cotton on an applicator. 

Sprue (Thrush; Muguet (Ft.) ; Soor (Ger.)). — Sprue is a para- 
sitic growth on the mucous membrane of the buccal cavity of the 
infant. It may spread to the nose in cases of cleft palate ; in other 
cases it may spread to the pharynx, larynx, oesophagus (Parrot, and 
even to the stomach (Parrot, Henoch, !Northrap)). The latter sit- 
uation is not favorable to its growth. The parasite has been found 
in the intestinal movements of infants suffering from the disease. 



DISEASES OF TEE MOUTH. 477 

Nature. — Sprue is a mould fungus. Its classification by various 
authors varies with the species examined. Older authors classed 
sprue with the oi'dium as Oidium albicans. Rees, Grawitz, and 
Kehrer classified it as a Mycoderma albicans, consisting of conidia 
and mycelia. Plaut classifies it as a common mould fungus (Monilia 
Candida). 

In the early stages it presents large or small irregular whitish 
masses. These may at first be very minute, covering only the sum- 
mits of the papillae of the tongue. On the buccal mucous membrane 
they may be as large as a pin's head or coalesce into masses resembling 
curdled milk. They may be seen on the roof of the mouth, on the 
soft palate, tonsils, and posterior pharyngeal wall. If the affection 
is progressive, the tongue and inner surface of the cheeks become 
coated with a white, closely adherent pellicle. In neglected cases the 
sprue may be of a yellowish color if sarcinse are present, or blackish 
or grayish in hue if other fungi have obtained lodgement. Consid- 
erable force is required to dislodge the growth from the mucous mem- 
brane, and the operation will cause bleeding and considerable pain 
and traumatism. 

Occurrence. — Sprue is introduced into the mouth from without. 
It is present in the vaginal secretions of the mother, and has been 
found on the breast nipple. An abrasion of the mucous membrane 
must exist in order that the fungus may obtain lodgement. It is 
therefore found in infants whose mouths have been harshly washed 
with unclean fingers or into whose mouths unclean breast or bottle 
nipples have been introduced. The fungus having gained access to 
the cement-substance between the epithelial cells, proliferates into 
the deeper layers of epithelium, and may even invade the underlying 
connective tissue. Sprue carries with it any other bacterial flora 
which may be present in the mouth. A perfectly normal mucous 
membrane is invulnerable to sprue. The sprue conidia and mycelia 
are found in the secretions of the mouth of the normal baby. Sprue 
is seen chiefly in infants whose health is below the average, who are 
inmates of institutions, or who have been in unhygienic surroundings. 

Henoch describes cases of sprue of the stomach. This is admit- 
tedly rare, and occurs in the form of slightly prominent plaques. 
Parrot describes sprue of the gastric mucous membrane as not 
infrequent. 

Symptoms. — The local symptoms are due to the presence of the 
growth. In mild cases the patches are few in number and very 
minute. In neglected cases not only is the whole mouth the seat of 
the disease, but also evidences of infections of a pyogenic nature occur 
in the form of erosions of the buccal mucous membrane, yellowish 
plaque-like ulcerations ami fissures which bleed easily. There is 



478 DISEASES OF THE MOUTH. 

dryness of the mucous membrane which has not been attacked or 
which has been freed from the fungus. Sprue, in fact, causes dis- 
tinct reaction of the healthy mucous membrane in the vicinity of its 
invasion. Infants, even in the early stages, suffer from mild disturb- 
ances of the gastro-enteric tract, manifested by vomiting and greenish 
movements. In neglected cases marantic symptoms are also present. 
Older writers (Parrot) believed sprue to be a causal factor in athrep- 
sia, but it is simply a complication. 

That pain is felt is evinced by the lack of desire to nurse. A 
febrile movement occurs if the intestinal tract is involved. 

Treatment. — Prophylactic. — Everything that is introduced into 
the mouth of the infant should be scrupulously clean. If the infant 
is breast-fed, the breast nipple should be cleansed before and after 
nursing with a pledget of cotton moistened with boric acid solution. 
The infant's mouth should not be cleansed after nursing. In cases in 
which the roof of the mouth has been carelessly cleansed there are not 
only the aphthae of Bednar, but also sprue and other aphthae in the 
median line as a result of traumatism to Epstein's pearls. If infants 
are fed artificially, the nipple of the nursing-bottle should be boiled 
in soda solution once daily. If these precautions are carefully 
observed, and the fingers never introduced into the infant's mouth, 
sprue will rarely if ever occur. The normal epithelium and normal 
secretions are safeguards against the fungus. 

Curative. — The growth should be removed by cleansing the mouth 
gently three times a day with a saturated solution of boric acid. The 
utmost gentleness should be used. Even in mild cases the removal 
of the sprue may extend over a number of days, because the parasite 
quickly reproduces itself . I use one piece of absorbent cotton attached 
to an applicator of wood or a tooth pick for the roof of the mouth, 
another for the tongue, and another for the cheeks and lips. If it 
can be avoided, the mucous membrane should not be caused to bleed. 
If aphthae exist, they should be touched lightly with a 2 per cent, 
solution of silver nitrate. The bowels should be opened by an initia- 
tive mild cathartic. Everything should be scupulously clean. The 
severe cases, in which there is a septic condition due to extension of 
the sprue to the gastro-enteric tract, occur chiefly in foundling asy- 
lums. The infants die of septic infections. In private practice the 
prognosis is good if the case is seen early and correctly treated. 
Baginsky recommends potassium permanganate (1 : 150) ; others rec- 
ommend corrosive sublimate (1: 2000), or formalin (1-100) (Holt), 
but boric acid will be found to be equally satisfactory. 

Aphthous Stomatitis (Stomatitis Aphthosa). — In this condition 
there are formed on the soft and the hard palate, the mucous mem- 
brane of the gums and tongue, and on the inner surface of the lips 



DISEASES OF TEE MOUTH. 479 

and cheeks, small, round, yellowish superficial ulcerations. These 
ulcerations, which vary in form and number, may coalesce and form 
irregular plaques. It is a question whether the ulcerations are the 
remains of vesicles which have burst, thus exposing an ulcerated base, 
or whether they are primarily ulcers. I am inclined to the former 
view, for in the so-called herpetic aphthse of the tonsils the natural 
development of the aphthous ulcerations can be observed to advance 
from the vesicular to the ulcerative stage. This condition is very 
common in infancy and childhood, and according to Monti is most 
frequent between the first and the third year. 

Etiology. — The etiology is still obscure. Some authors consider 
aphthous stomatitis an acute infection derived from the gut, possibly 
caused by toxins generated in contaminated milk (Forcheimer, Hitter, 
Kmeriem, Schamtyr). Others, basing their opinion on bacteriolog- 
ical studies, regard it as a purely local affection. The clinical course 
of the disease tends to support the former view. It has been com- 
pared by Forcheimer and others to the so-called foot-and-mouth dis- 
ease of cattle. 

The condition may occur idiopathically or may complicate intes- 
tinal infection, the exanthemata, bronchitis, tonsillitis, and pneumonia. 
Some authors believe that the affection may be communicated to 
others by the secretions of the mouth. 

Bacteriology. — The forms of bacteria most commonly found in the 
ulcerations are the various streptococci and staphylococci (Jadas- 
sohn). Bernabei has found the pneumobacillus of Friedlander. As 
these bacteria are present in the normal secretions of the mouth, it is 
doubtful whether they bear a causal relation to the condition. 

Symptoms. — These aphthse vary from the size of a pin's head to 
that of a split pea. They are invariably surrounded by an areola 
of inflamed mucous membrane. The outline of the ulceration may 
be round or irregular ; as a rule the ulcerations are superficial. At 
the line of junction of the teeth and gums they may show a tendency 
to bleed if touched. There is considerable pain, with salivation, and 
in young infants also a distinct febrile condition and green diarrhceal 
movements. In other cases there may be an accompanying angina 
with swelling not only of the lymph-nodes at the angle of the jaw, but 
also of those underneath the jaw. In addition there are loss of appe- 
tite, and restlessness at night. 

Course.' — In well-nourished infants and children the tendency is 
to limitation of the aphthaB and spontaneous recovery within three 
or four days. In marantic or badly nourished children in unhygienic 
surroundings, the aphtha^ are likely to spread, the ulcerations pre- 
senting the appearance of a mixed infection. Such eases are difficult 



480 DISEASES OF THE MOUTH. 

to control. As a rule, however, the disease runs its course without 
leaving any lasting ill results. 

Treatment. — The treatment of the cases in which the ulcerations 
or aphthae remain discrete and in which mixed infection does not 
occur is "begun with a saline cathartic, such as magnesia, or a dose of 
castor oil. The mouth should not be washed. Careless attempts to 
cleanse the mouth are likely to cause the aphthae to coalesce and spread, 
and also to cause intense pain. I administer a small dose of ferric 
chloride, made up with glycerin, every three hours. In most cases 
this will suffice. The use of potassium chlorate should be avoided 
with infants. If the edges of the gums adjacent to the teeth are 
affected, the teeth should be gently washed three times daily with a 
weak solution of tincture of myrrh or a saturated solution of boric 
acid. If the aphthae coalesce, they should be touched once daily with 
a 2 per cent, solution of silver nitrate. With intractable young chil- 
dren, care should be taken in washing the mouth not to traumatize the 
unaffected mucous membrane. 

Toxic Stomatitis. — I have seen a number of cases of stomatitis 
caused by irritant poisons, such as potash and ammonia. The chil- 
dren so affected had attempted to drink a solution of potash or 
ammonia from a bottle left within their reach. 

Symptoms. — The symptoms were purely local. The mucous mem- 
branes of the lips had a characteristic oedematous, swollen, and trans- 
parent appearance, the buccal mucous membrane and the tongue were 
pale and oedematous, and the papillae were erect and transparent. 

Treatment. — The treatment is expectant. A mixture containing 
bismuth subcarbonate seemed to give most relief. On subsidence of 
the oedema the mucous membrane presented a dry appearance. Some- 
times small aphthous ulcerations appeared, which healed under appli- 
cations of a 2 per cent, solution of silver nitrate. 

In one case, five years of age, symptoms of oesophageal stricture 
were present three months after the ingestion of the irritant. Strict- 
ures of the oesophagus are more common after the ingestion of potash 
or lye solutions than after corrosion by ammonia. 

Ulcerative Stomatitis (Stomatitis ulcerosa; Stomacacce; Ger., 
Mundfaule) . — Ulcerative stomatitis is a disease of the mucous mem- 
brane of the mouth, gums, and tongue, characterized by ulceration 
with a fetid odor. 

Etiology. — The etiology is still obscure. Friihwald and Bernheim 
found bacilli and spirochsetse (spirilla) in the ulcers. The fetid odor 
of the breath was reproduced in the cultures of Bernheim. The 
bacillus is lanceolate in form and resembles the diphtheria bacillus. 
These bacilli and spirilla are probably identical with those described 
in 1896 by Vincent as occurring in hospital gangrene. 



DISEASES OF THE MOUTH. 481 

Occurrence. — The affection is most common between the fourth 
and the eighth year. The period of infancy seems to be exempt, in 
my opinion, because of the absence of teeth. It occurs in children 
who have been neglected or who have lived in unhygienic surround- 
ings, and is therefore very common in patients of clinics and dis- 
pensaries. 

Symptoms. — In the milder forms there is a line of yellowish ulcer- 
ation along the margin of the gums at the point of contact with the 
teeth, and the adjacent mucous membrane is red and inflamed. 
When the gums are touched either in washing or in examination, 
bleeding readily occurs. There is a fetid odor to the breath, the 
tongue is coated ; some children have pain and loss of appetite, and 
a slight fever. In the severer cases there are deep ulcerations along 
the margins of the gums, which bleed on the slightest provocation. 
Ulcers with a greenish-yellowish base are seen along the border of the 
tongue and beneath it. In these cases the lymph-nodes beneath the 
body of the jaw are enlarged and painful as a result of the infection. 
The salivation, pain, and local disturbance are considerable, and the 
fetor oris is marked. The buccal mucous membrane at the points of 
contact with the teeth may be deeply ulcerated, indurations of the 
tissues of the adjacent mucous membrane being also present. Small 
particles of necrotic tissue are seen to flow away in the saliva. So 
great is the pain that some children refuse to open the mouth or par- 
take of food. I have seen the teeth become loose and necrosis of the 
alveolar process result. Under the latter condition there is much 
swelling of the tissues above and beneath the jaw with enlarged 
lymph-nodes. The tonsils may also be the seat of ulceration of the 
same character as that occurring at the lateral margin of the tongue. 

Treatment. — Cleanliness is the first step toward lessening the 
intensity of the inflammation. The mouth is washed every three 
hours with a solution of potassium chlorate, made by adding a tea- 
spoonful of the saturated solution to a small glassful of water, or 
with a 0.5 per cent, solution of formalin. Internally, liberal doses 
of ferric chloride, made up with glycerin and water, have given the 
best results. If there are extensive ulcerative processes along the 
gums, the line of ulceration is gently touched, once a day with a 10 
per cent, solution of silver nitrate. In addition, the patient must 
have an abundance of fresh air, and is given a nutritious fluid diet, 
with fresh fruits and a small allowance of wine. 

Gonorrhoeal Infection of the Mouth.— Gonorrhoea] or blennor- 
rhceal stomatitis is an infection of the mucous membrane of the mouth 
by the gonococcus of Neissor. Infection occurs only in places where 
the mucous membrane has been injured. There may be an associated 
gonorrheal infection of the eyes or the vulva and vagina. The infee- 

31 



482 DISEASES OF THE MOUTH. 

tion may be introduced into the month by the fingers of the nurse or 
mother. If the mother is suffering from gonorrhoea, infection may 
occur at the time of birth or subsequent to parturition. The cases 
thus far reported (Rosinski, Kast) have developed from two to thir- 
teen days after birth. 

Symptoms. — The constitutional disturbance is slight in some cases ; 
there is no fever, no pain, and no interference with suckling. In 
other cases I have observed depression and sepsis with a mixed 
phlegmonous infection of the fauces, inability to nurse, and asthenia 
with death. The lesions occur on those parts of the hard palate most 
likely to suffer from traumatism and subsequent infection — the parts 
favored by Bednar's aphthse, the median raphe in the alveolar proc- 
esses of the hard palate, and the anterior two-thirds of the tongue. 
Inspection reveals yellowish-white patches, due to infiltration of the 
superficial epithelial layers of the mucous membrane with inflamma- 
tory products. There is no pseudomembranous formation, but a pul- 
taceous thickening. There is little tendency to spread, and no inflam- 
matory reaction of the adjacent mucous membrane. The discharge 
is so slight that the saliva remains clear. 

Examination of the secretion from the patches on the hard palate 
(which are generally symmetrical) and on the tongue reveals the 
presence of abundant gonococci not only on the surface, but also in- 
vading the mucous membrane along the cement-substance between 
the epithelial cells. The infection differs from that seen in adults 
(Cutler), in whom great constitutional disturbance and severe inflam- 
mation of the whole mucous membrane of the mouth are combined 
with a profuse ichorous buccal discharge and with pain. Some cases 
recover; others, as mentioned above, develop sepsis and asthenia 
and die. 

Treatment. — The treatment is limited to the enforcement of strict 
cleanliness, and to local applications of weak solutions of silver nitrate 
(2 per cent.). The mouth may be washed twice daily with a 10 per 
cent, solution of protargol or argyrol. 

Pseudodiphtheritic Stomatitis. — This form of stomatitis was first 
accurately described by Epstein. It is seen in newborn infants who 
have sustained a traumatism of the mucous membrane of the mouth. 
An infection of the injured membrane with streptococci results in 
the formation of a membrane resembling that seen in true diphtheria. 
These cases occur in foundling-hospitals and amid unhygienic sur- 
roundings. 

Symptoms. — The pseudomembrane is of a greenish-yellow hue, and 
may spread over the hard and soft palate, the tongue, and the pharynx. 
It may involve secondarily the entrance to the larynx, as happened 
in the cases of Epstein, and the epiglottis and oesophagus as well. 



DISEASES OF THE MOUTH. 483 

Gastro-intestinal symptoms and secondary septic pneumonia are 
developed. The temperature may, as in other cases of sepsis, be 
normal, or even subnormal. As a rule, the lymph-nodes are not 
enlarged. The condition must be differentiated from sprue and 
aphthous stomatitis. Aphthous stomatitis does not show any pseudo- 
membrane; microscopical examination will aid in differentiating this 
disease from sprue and gonorrheal stomatitis. 

Treatment. — Inasmuch as these cases are of septic origin, their 
course is progressive. On the other hand, small patches of mem- 
brane may be limited by applications of a 10 per cent, solution of 
silver nitrate. The membrane should not be peeled off, nor should 
the mouth be cleansed with the finger. Antistreptococcic serum is' 
of no use in these cases. 

Noma (Cancrum Oris). — Noma is a specific bacterial infection 
which attacks the tissues of one or both sides of the face, resulting in 
gangrene and destruction of the soft and hard parts. Babes and 
Zambolovici differentiate it from all other forms of gangrenous sto- 
matitis and gangrene, such as those described by Henoch as occurring 
on the vulva. 

Etiology. — The etiology is still obscure. Investigations thus far 
tend to show that several conditions clinically similar have been found 
to have a diverse etiology. Babes and Zambolovici isolated a very 
minute bacillus, and by inoculation experiments in animals produced 
typical noma. They found that this bacillus extends through the 
mucous membrane of the mouth, especially that of the gums. Accom- 
panying it are a large number of streptococci, spirochsetae, and other 
bacilli. The latter play an active secondary role in the production 
of the gangrene. Gangrene is caused by an overwhelming bacterial 
invasion of the tissues. The toxins produced cause death of cell-life 
and necrosis in mass. In another set of cases, Walsh found the 
bacillus of diphtheria. These cases would appear to correspond to 
those published by Freimuth and Petruschky, who found a bacillus 
identical with the diphtheria bacillus in cases of noma of the vulva. 

The greater number of cases of noma occur after measles. It 
may follow any of the exanthemata, typhus, typhoid fever, or any 
disease through which the power of resistance to infection is lessened. 

Symptoms. — Henoch and Baginsky hold that in many cases an 
ulcerative stomatitis has preceded the main affection. The disease 
begins on the mucous membrane and invades the cheeks from within. 
Henoch alone has seen it begin from without in the form of a phleg- 
mon of the cheek. It is first seen as a small ulcer with a blackish- 
gray base on the buccal mucous membrane opposite the teeth, or it 
may begin as a vesicle with serosanguinolenl contents. After a 
period of time varying from a lew hours to three or seven days the 



484 DISEASES OF THE MOUTH. 

tissues of the cheeks become brawny and ©edematous, the oedema 
involving the eyelids and lips. A dark, livid area finally appears 
on the corresponding exterior surface of the cheek. This area becomes 
black and gangrenous. Perforation and spreading of the gangrene 
rapidly result. The jaw may necrose and the teeth fall out. The 
process may spread downward along the neck, involving the shoulder 
in an oedematous, emphysematous, gangrenous mass. The indura- 
tion of the tissues of the cheek occurring in many forms of stomatitis 
ulcerosa should not be confounded with this affection ; in these forms 
of induration gangrene is absent. In all cases of noma a marked 
gangrenous odor pervades the atmosphere about the patient. 

The general condition of many cases is astonishingly good at 
first. The children seem unconcerned, and sit up in bed and play. 
The patient finally succumbs to the toxaemia accompanying such 
great destruction of tissue. There may be a febrile movement (103° 
to 104° F., 39.4° to 40° C.) . The swallowing of gangrenous products 
in some cases causes a prostrating and uncontrollable diarrhoea of a 
septic character. There is little or no pain. Death results within 
two or three weeks, either from general toxaemia and heart failure or 
complicating pneumonia. 

Occurrence and Prognosis. — From a study of the literature, noma 
is found to occur most frequently between the second and the seventh 
year. The mortality is very high — fully 75 per cent. (Woronichin). 

Treatment. — The most diverse methods have been employed in an 
endeavor to arrest the progress of this affection. To support the 
strength of the patient is the first consideration ; careful ventilation, 
antiseptic and deodorizing solutions to destroy the gangrenous odor, 
good food, and wine, are all of service. 

The local treatment varies. Some authors advise dusting iodo- 
form on the gangrenous area ; others advocate the use of caustic zinc 
pastes in order to determine the line of demarcation between the gan- 
grenous and healthy tissues. The Paquelin cautery with knife-blade 
attachment has been employed to remove the gangrenous tissue. So- 
lutions of boric acid, thymol, and salicylic acid, should be freely 
employed to keep the mouth and parts clean. 

In those cases, probably a distinct group, in which the bacillus of 
diphtheria is found, diphtheria antitoxin should be injected in proper 
doses. 

DISEASES OF THE TONGUE. 

Congenital Anomalies of Size (Macroglossia). — The tongue of 
some infants who are otherwise normal is unusually large- and pro- 
trudes slightly from the mouth, but is of normal shape. It is pointed, 
but somewhat thicker in the middle (Fig. 104). As the infant grows 



DISEASES OF THE TONGUE. 



48o 



older this anomaly becomes less apparent. In extreme cases the 
tongue protrudes from the mouth as a tumor mass. It is discolored 
— generally of a livid hue — and becomes ulcerated, especially at the 
line of the teeth. Infants thus affected cannot nurse, and the tongue 
must be reduced in size by surgical means. This congenital enlarge- 
ment of the tongue may be due to an increase either of the connective 
or muscular tissues, or of both. In other cases the lymph-spaces of 
part or the whole of the organ are dilated — there is a lymphangioma 
of the tongue. 

There are thus two forms of macroglossia — the one is called 
macroglossia lymphatica congenita, the other macroglossia congenita 
hypertrophica. The lymphatic form shows for the most part a gross 

Fig. 104. 




Simple macroglossia. 



hypertrophy of the organ and more rapid growth, combined with sec- 
ondary changes in the lower jaw and teeth. The surface of the 
tongue is changed in appearance through defects of the epithelium 
and the results of inflammatory processes. The papillae are enlarged, 
the organ is bluish red, nodular, not changed by muscular action and 
can be compressed. Speech is for the most part changed. The 
tongue in the hypertrophic form is smooth, the surface enlarged, the 
growth slow, the tongue loss movable than normally and changed by 
muscular action. It cannot be compressed, as in the lymphatic form, 
and is less apt to become inflamed. The surgical procedures have 
consisted in compression, excision, and an ignipuncture, the latter 
being the most advisable (Eras). In cretins and the Mongolian 
forms of idiocy the tongue is also enlarged. It is broad, thick and 



486 



DISEASES OF TEE TONGUE. 



flat, and protrudes from between the lips. In these patients the con- 
dition calls for no special treatment. 

Ringworm of the Tongue (Wandering Bash of the Tongue; 
Lingua Geographica) . — Ringworm of the tongue is a common affec- 
tion of infants and children. It was probably first described by 
Santulus in 1854. Parrot regarded it as a symptom of hereditary 
syphilis — a view which has no clinical support. 

In 103 cases reported by Bohro, the condition occurred sometimes 
in early infancy, sometimes as late as the twelfth year of life, and 
was most frequent between the first and the second year. 

Etiology. — The etiology is obscure. Bohm believes it to be con- 
nected with a lymphatic diathesis (scrofulosis). It is found chiefly 
among children of the lower classes. It may, however, be seen in 
children in good hygienic surroundings and who are otherwise healthy. 



Fig. 105. 



Fig. 106. 





Ringworm or wandering rash of 
the tongue, lingua geographica. 



Epithelial desquamation of the 
tongue. 



If scrapings from the borders of the patches of an affected tongue 
be examined microscopically when fresh, large numbers of zooglsea 
of coccus form, in some cases mingled with sarcinse, will be seen. 
The presence of the latter micro-organism explains the yellow color 
of the border of the patches in some cases. The disease sometimes 
affects several children of a family. 

Symptoms. — The symptoms are limited to the appearance of the 
patches on the tongue. At the tip, but most frequently at the sides 
of the tongue, .are seen areas sharply circumscribed by narrow, sin- 
uous, perfectly oval or round borders (Fig. 105). The border is not 
only distinctly raised above the epithelium of the tongue, but also 
is of limited breadth and has a more pronounced whitish or yellow- 
white color than the rest of the tongue. Inside this border, if the 



DISEASES OF THE TONGUE. 487 

patch is oval, the tongue seems to be denuded of its epithelium and 
is reddish in color. This condition should be differentiated from 
desquamation of the epithelium on the dorsum of the tongue, which 
presents a similar appearance, but in which the patches have not the 
band-like border (Fig. 106). Children do not appear to suffer incon- 
venience from this condition of the tongue. 

Treatment. — Treatment of the most diverse kinds, including local 
application of tincture of iodine and the use of ferric chloride, has in 
my experience failed to produce results. 

Desquamation of the Epithelium of the Tongue.— In this con- 
dition, which has been confounded with that just described, there are 
seen areas of irregular size and apparently denuded of epithelium. 
The boundary of these areas is sharply outlined, but the epithelium 
bounding the areas is apparently normal (Fig. 106). The tongue 
looks as if the epithelium had been scraped off. The condition 
demands no treatment, since it is only a symptom of mild derange- 
ment of the digestive processes. 

Tongue-swallowing". — Tongue-swallowing is a term applied to a 
peculiar phenomenon seen in some infants who are the subjects of 
nasal obstruction. Infants normally breathe through the nose when 
at rest, the tongue being in contact with the roof of the mouth. If 
nasal breathing is obstructed either by swelling of the mucous mem- 
brane or by deformity of bone, or adenoids, the infant experiences 
great difficulty in breathing through the nose. As a result, not being 
accustomed to keeping the mouth open and the tongue on the floor of 
the mouth, the ineffectual efforts at nasal and mouth-breathing cause 
the infant to draw the tongue inward. The tip of the organ folds 
on itself . and may be drawn backward into the mouth in the efforts 
at mouth-breathing, causing a peculiar snapping noise to be heard on 
inspiration. 

Treatment. — The remedy in these cases is nasal douching, and 
dilatation of the nasal passages with pledgets of cotton. The cotton 
is rolled around a probe or applicator, moistened with castor oil, 
introduced once a day into the nares, and allowed to remain about 
five minutes. If the infant has adenoids they should be removed. 

Tongue-tie. — Tongue-tie is a condition for the relief of which the 
physician is frequently consulted. Some mothers will ascribe ineffi- 
cient nursing to this condition. With a breast secreting sufficient 
milk tongue-tie would not prevent nursing. The existence of the 
condition is readily detected if the organ is bifid at its tip when pro- 
truded. The frenulum will in such cases be seen to extend to the 
extreme tip of the tongue in a fan-shaped manner. 

Treatment.- -The frenulum being membranous is easily divided, 
li should be caught in (he bifid groove of the pocket-case director 



488 DISEASES OF THE (ESOPHAGUS. 

and made tense, and the membranous portion divided with a pair of 
round-ended scissors. The ends of the scissors should be directed 
to the floor of the mouth. There is little bleeding. The infant 
should be placed at the breast directly after the operation, so that the 
act of suckling may stop the hemorrhage. 

MALFORMATIONS OF THE UVULA. 

The uvula is often bifid in infants. This condition is only of 
anatomical interest. There are cases in which the uvula is relaxed 
and elongated. In one case, in a boy -Q.ve years of age, the uvula 
was so long that it gave rise to an incessant night-cough. On excision 
of the uvula the cough ceased. 

DISEASES OF THE (ESOPHAGUS. 

Congenital Anomalies. — Branchial Fistulae. — Among the congen- 
ital anomalies connected with the oesophagus is the so-called fistula 
colli congenita. This is due to a faulty closure of the branchial clefts 
in foetal life. This fistula is generally unilateral, and is found at the 
inner side of the sternomastoid muscle. It may be bilateral. It 
generally leads to the pharynx or oesophagus, and may end in a blind 
canal. The canal may discharge mucus containing ciliated epithe- 
lium and leucocytes. Hennes described a cartilaginous growth in the 
neck, of which I have seen an instance. It occurs in the same situa- 
tion as the above fistula, and is traceable to the same faulty closure 
of the branchial clefts. 

Branchial Cysts. — Branchial cysts are cystic tumors of the neck 
and some parts of the head, originating from congenital defects of 
development. The primary origin of these tumors corresponds to the 
location of one of the branchial clefts, most frequently the second 
and third, in the vicinity of the larynx and pharynx. They are in 
intimate relation with the sheaths of the large vessels of the neck, the 
jugular vein, and carotid artery. The cysts are classified, according 
to their contents, into mucous, atheromatous, serous, and hematocysts. 
Branchial cysts are of rare occurrence. The serous variety is ob- 
served in early life, either congenital or develops during infancy or 
childhood, whereas the atheromatous cysts are seen in early adult life. 
These cysts are seen most frequently on the left side of the neck. 
Their further consideration and treatment is of a surgical nature. 

Diverticula of the (Esophagus. — These occur in childhood, are con- 
genital in origin, and are accompanied by symptoms of difficult deglu- 
tition of solid foods, though fluids may be swallowed. In some cases 
the food collects in the diverticulum, causing swelling of the neck, 



DISEASES OE THE (ESOPHAGUS. 



489 



with spells of coughing and consequent emptying of the diverticulum. 
With the difficulty of deglutition there is regurgitation of the food 
after eating. In a case recorded by Kurz there were undulatory 
movements at the side of the neck and gurgling noises heard on swal- 
lowing. A sound could be passed into the stomach, but at the junc- 
tion of the upper third with the lower two-thirds of the oesophagus the 
sound passed into a pocket. In this case food could be caused to pass 
into the stomach while the patient was placed in a certain position. 
In an interesting case described by Adams the diverticulum commu- 
nicated with the trachea. 



Fig. 107. 




Congenital branchial cyst. Infant seven months of age (Dr. Henry Heiman's case). 

The above diverticulum may be primary, of the congenital variety ; 
or secondary, due either to a stricture of the oesophagus and dilatation 
above the stricture, or to traction from without on the oesophagus by a 
caseous lymph-node. 

Congenital Stricture of the (Esophagus. — Sneider has collected 15 
cases of congenital stricture of the oesophagus, most of which gave no 
symptoms during infancy and childhood. The stricture in these cases 
was either in the form of a ring of tissue or folds with thickening of 
the mucosa. They were present either in the upper or lower part of 
the oesophagus. Only 2 of the 15 cases died during childhood, the 
symptoms appearing for the most part in early youth. 

The case recorded by Turner was thai oi' a child eighteen months 
old. It had always suffered from difficulty in swallowing, and 
weighed only 14-J pounds. The mother said that since the period of 



490 DISEASES OF THE (ESOPHAGUS. 

weaning the child had become emaciated, and the difficulty in swal- 
lowing had increased so that finally all food was rejected. A sound 
having the diameter of the small finger could not be introduced into 
the stomach. Postmortem, the stenosis was found at the cardiac end 
of the stomach and was of the size of a "No. 2 catheter. 

Congenital Atresia or Absence of the (Esophagus. — The oesophagus 
may be entirely wanting, and in such cases other organs show anoma- 
lies ; or there may be atresia of the middle third of the oesophagus ; 
or the oesophagus may communicate in part with the larger bronchi. 
The stomach may be absent in some of these cases. In such cases 
the infants swallow, choke, have cyanotic attacks, and in three or four 
days cease to live. In one case published by Simon the oesophagus 
ran circularly around the trachea; the patient survived and died in 
adult life. 

(Esophagitis. — Any inflammation of the mouth or the pharynx 
may extend into the oesophagus, such as croup, diphtheria, burns, cor- 
rosions, sprue. These affections cause no characteristic symptoms 
apart from the primary disease. 

Caustic (Esophagitis (Traumatic Stricture of the (Esophagus). — 
This is caused by the action of caustic alkalies or mineral acids on 
the tissues of the oesophagus, and the intensity of the corrosion varies 
with the amount and strength of the caustic taken internally. The 
caustic alkalies, such as potash and ammonia, are especially likely to 
be swallowed by children. The effects of the corroding agent are 
shown first externally. If a concentrated mineral acid has been taken, 
there is a brown or a black eschar. In less concentration we have 
white or grayish eschars, and later mild inflammatory reaction. 
Alkalies cause gelatinous swelling of the mucous membranes covering 
the lips, tongue, and buccal cavity. If the alkali be very strong, the 
tissues are converted into a yellow or brownish mass, and the fatal 
issue sets in before any reaction takes place. If the agent be dilute, 
superficial ulcers form after the primary corrosion. Reaction sets 
in, and, following the inflammatory stage of the reaction, cicatricial 
effects result, such as stricture. 

Symptoms. — The symptoms accompanying the swallowing of cor- 
rosive poisons are pain, which is constant, incessant crying, restless- 
ness, due to a burning sensation in the mouth, attended with great 
pain and difficulty in swallowing. In some cases blood and purulent 
matter are vomited. There is great thirst. In other cases, where 
the concentration of the alkali has not been great, the lips are swollen, 
the mucous membrane of the mouth presents a whitish, gelatinous, 
swollen appearance. There is constant salivation ; the children refuse 
to take solids or liquids, inasmuch as the least attempt at swallowing 
causes great pain. 



DISEASES OF THE (ESOPHAGUS. 49 J 

Treatment. — The treatment of these eases is at first medical. De- 
mulcents and milk are given in large quantities, and the physician 
should refrain from examinations with instruments lest perforation 
of the oesophagus or stomach result. After a few weeks, the primary 
effects of the corrosion having passed off and cicatrization of the 
ulcers having taken place, a stricture of the oesophagus results. The 
treatment of this stricture is surgical. 

Peri-oesophageal Abscess (Iletro-cesophageal Abscess). — Griffith 
has reported 12 cases of this affection. It is not infrequent in infancy 
and childhood. The oesophagus begins above at the seventh cervical 
vertebra, lying in front of the spine. It passes behind the right 
bronchus between the two pleural sacs, behind the pericardium, and 
finally passes through the diaphragm. Any affection of the spine, 
pleura, pericardium, or lymph-nodes at the root of the lung may either 
cause pressure on the oesophagus, involve it in inflammation, or, if 
suppuration exists, the pus may break into the lumen of the oesoph- 
agus. Cases are recorded in which the pressure of an intubation 
tube or diphtheria of the pharynx has involved the perioesophageal 
tissue and caused abscess; or a foreign body in the oesophagus may 
cause perforation and ulcer, involving the adjacent connective tissue. 
If a foreign body is lodged in the oesophagus and is contaminated, as 
in the case of Soltmann, with actinomycosis, abscess of the oesophagus 
and lung may result, with actinomycosis of the latter organ. The 
most frequent cause, however, of peri- or retro-oesophageal abscess is 
disease of the vertebrse of a tuberculous nature. 

Symptoms. — These will vary with the cause. An abscess of the 
pleura or a lymph-node pressing on the oesophagus will give symptoms 
of oesophageal stenosis. In some cases the pressure may interfere 
not only with deglutition but with respiration, and give rise to symp- 
toms resembling laryngeal stenosis, necessitating intubation. As 
soon as the tube, however, is withdrawn from the larynx, the dyspnoea 
returns. The larynx may also be pushed to one side. There may 
be temperature, due to the primary disease. In one of my own cases 
there were spasmodic attacks of coughing, accompanied by cyanosis. 
and in one of the attacks a discharge of pus. The source of the pus 
in this case was probably an empyema which had opened into the 
oesophagus. These attacks were repeated at intervals, though with 
less expectoration of pus. The child finally made a good recovery. 

In spondylitis there will be symptoms of disease of the vertebra. 
If perforation occur from a bronchus or caseous gland, there arc 
attacks of coughing, vomiting o( food and pus, and finally symptoms 
resembling putrid bronchitis, and in some cases lung gangrene. 

Diagnosis. — In some cases the diagnosis is not only difficult, but 
impossible. If the cause is evident ami the abscess can be reached 



492 DISEASES OF THE (ESOPHAGUS. 

with the finger, the diagnosis can be made ; but if the abscess is deep- 
seated, beyond the reach of exploring instruments, the disease is diag- 
nosed only at the autopsy table. If the swallowing of a foreign body 
has preceded symptoms which resemble retro-cesophageal abscess, an 
#-ray should be taken to locate the body. 

Prognosis. — The prognosis in deep-seated retro-oesophageal abscess 
is bad; that in spondylitis likewise. The spontaneous rupture of the 
abscess, with discharge of pus externally and recovery, is exceptional. 
The spontaneous rupture of a retro-oesophageal abscess may result in 
pus finding its way into the larynx, thereby causing suffocation. 

Treatment. — The treatment of retro-oesophageal abscess, if diag- 
nosed promptly, is surgical. It may be stated, however, that these 
abscesses are best opened from without, and we should hesitate to 
make an internal incision in a deep-seated retro-oesophageal abscess. 



SECTION VII. 

DISEASES OF THE STOMACH AND INTESTINES. 

Classification. — The classification of the diseases of the gastro- 
enteric tract occurring in infancy and childhood must necessarily be 
schematic for the present, for much is yet to be learned, from chem- 
ical, physiological, and pathological standpoints, concerning some of 
these affections. Any classification, therefore, must be founded on a 
mixed etiological basis, and must, of necessity, be subject to future 
revision. For the present we may divide these diseases into : 

First. — Those due to some congenital defect in the constitution 
or anatomical construction of the body. 

Second. — Those which are due to some fault in the functional 
assimilation of the food. The food in these cases is free from bac- 
terial contamination and is not assimilated and the infant does not 
thrive. There is no pathological lesion in these cases. In this class 
belong the acute dyspepsias, both of the stomach and intestines, 
various forms of vomiting, colic and tympanites, all leading to the 
main result, an atrophy or marasmus. 

Third. — Those disturbances due to infection. Bacteria and their 
toxins are the agents by which these diseases are brought about. 
In this class belongs the acute gastro-enteric infections, including 
cholera infantum. In these diseases the anatomical lesion, if any 
exists, is in the majority of cases only temporary, for the patients 
recover. In the fatal cases the anatomical lesions are very slight and 
disproportionate to the severity of the disease, being due, it is at pres- 
ent supposed, to the direct action of the bacteria and their toxins on 
the superficial structures of the stomach and gut. 

Fourth. — Those diseases which are due to the direct action of the 
bacteria themselves, which, in addition to causing constitutional symp- 
toms, due to the passage of the toxins into the circulation, also cause 
serious anatomical changes in the tissues of the gut, some of these 
changes causing eventually the death of the patient. In this class we 
would place dysentery of infancy and childhood, and the various 
forms of ileocolitis, which have, as yet, no firm etiological basis estab- 
lished by investigation and experiment. 

Fifth. — A series of diseases caused by some anatomical condition 
or neurosis. In this class must be placed the forms of congenital 
stenosis of the pylorus, dilatation o( the stomach, which, though pri- 
marily caused by dyspeptic disturbances, eventually supervenes as the 

498 



494 DISEASES OF THE STOMACH AND INTESTINES. 

result of anatomical weakness of the muscular structures of the 
stomach. In this class we would place the various forms of consti- 
pation depending upon congenital dilatation of the colon. 

The Stomach. — Anatomy. — The oesophagus enters the diaphragm 
at about the level of the ninth dorsal vertebra ; the cardia is on a level 
with the tenth dorsal vertebra ; the pylorus is in the majority of cases 
situated in the median line, but in some cases is slightly to the right 
of it. It is midway between the tip of the xiphoid cartilage and the 
umbilicus, and, being behind the liver, is not normally palpable. 
The stomach lies in an oblique position, passing from behind forward 
and downward. The pylorus is from two to two and one-half bodies 
of a vertebra lower than the cardia. In the newborn infant the infe- 
rior portion of the stomach has a fundus form (Pfaundler), which 
later becomes more marked. Occasionally there is no fundus, and 
the stomach is then of cylindrical shape. Between the time of birth 
and the seventh month the fundus of the stomach increases to fully 
twice its original length (Pfaundler). 

Capacity. — The capacity of the stomach is still a matter of specu- 
lation. The absolute capacity, as given by Fleischman, Drewitz, 
Pfaundler, Holt, and Potch, varies with the method employed to 
determine it. The work thus far done has been carried out on the 
cadaver, and, moreover, the methods employed presuppose an amount 
of pressure (14 c.c. to 30 c.c.) of water which does not exist in the 
normal state during life. The stomach contracts after death (sys- 
tole) ; the distention with air or fluids is thus partly artificial. Lastly, 
the stomach capacity is of little aid in determining the point at issue 
— the quantity of food which should be taken by a healthy infant 
at each feeding. Figures giving absolute stomach capacity are useful 
only as indicating the actual size of the organ when full of fluid, a 
condition rarely present during life. 

In the following table (p. 495) Plaundler's results are compared 
with those of others. They were obtained by postmortem distention 
with fluid at a pressure of 30 c.c. of water. Pleischman distended 
the stomach at 14 c.c. of water pressure. 

Function and Motility. — The stomach of breast-fed infants empties 
itself in two hours after the ingestion of a full nursing. If the 
quantity of milk taken is small, a shorter time suffices. Bottle-fed 
infants taking cows' milk need fully three hours to accomplish the 
same result. These facts teach that intervals of rest between the 
nursings, and a rest of four or five hours once in twenty-four hours, 
are necessary. 

Marking out the Stomach by Percussion. — This procedure is diffi- 
cult with infants and children. The normal stomach is rarely found 
outside of the left hypochondrinm. The liver fully covers the stomach 



DISEASES OF THE STOMACH AND INTESTINES. 495 

in the collapsed state. In the recumbent posture the stomach may 
be mapped out on the anterior abdominal parietes. It comes forward 
in the triangle formed on one side by the border of the left lobe of the 
liver and on the other by the border of the ribs. Above, the apex 
of the triangle is formed by a junction of the ribs and the left lobe 
of the liver. Below, the base of the triangle is of variable length. 
In the axillary line the fundus in a moderately distended state is in 
contact with the thoracic walls, between the liver above and the spleen 
below. Above, it is separated from the lung resonance by a strip of 
dulness (the left lobe of the liver) which changes position with the 
movements of the diaphragm. The tympanitic resonance reaches 
downward in a vertical direction from the sixth to the eighth rib. 
Behind this, tympany is limited by the posterior axillary line; in 

Fleisch- Drewitz. 

MAN 

c.c. c.c. 

At birth .....;....... 30 . . 

One week 45 

One month 77 99 

Two months ........... 79 115 

Three months 140 130 

Four months .. I ....... . . . 165 

Five months 290 253 

Six months 260 297 

Seven months 217 

Eight months 289 

Nine months . . . 510 

Ten months 375 350 

Eleven months 535 

Twelve months , . 500 

One to two years 220 588 

front, by the triangle above referred to. I have frequently been able 
to confirm these statements of Fleischman. Anteriorly, I have with 
the aid of a gastrodiaphane shown that the transverse colon passes in 
front of the stomach just beneath the liver. It should be remem- 
bered that tympanitic resonance in the epigastrium is not always due 
to the stomach. 

Acids of the Stomach. — When digestion is not in progress the 
stomach contains a tenacious, colorless mucus, neutral in reaction. 
When food is in the stomach, the reaction is acid. 

Hydrochloric acid is normally present in the stomach of the infant 
(Leo, Van Puteren, Wohlman) ; lactic acid only occasionally. ITeub- 
ner found 0.16 to 0.2 pro mille of lactic acid present. A considerable 
amount of hydrochloric acid unites with the salts and albumin of the 
milk, and is found as combined hydrochloric acid. When combina- 
tion is no longer possible, the residue appears as free hydrochloric 
acid. The amount of free hydrochloric acid depends on the quantity 
of milk ingested, and varies from 0.S to 2.1 pro mille. 1 have fro- 



Pfaund- 


ROTCH. 


Hot 


LER. 






CC. 


C.C. 


c.c 


30 


30 


36 


150 


75 


60 


175 


96 


99 


200 


100 


135 


230 


107 


150 


260 


308 


170 


295 


h 


264 


330 






365 






406 






445 






485 




243 


515 






640 







496 DISEASES OF THE STOMACH AND INTESTINES. 

quently failed to find free HC1 in the stomach contents of infants who 
are fed irregularly at frequent intervals. In healthy breast-fed in- 
fants free hydrochloric acid is found in from one and a quarter to 
two hours, and in bottle-fed infants in from two to two and a half 
hours after nursing. The effect of the lab-enzyme on the milk is 
marked in. breast-fed as compared with that in bottle-fed infants. In 
the former the action of the acid delays that of the lab-ferment, while 
in the latter coagulation of the casein occurs in a short time and in 
large flocculi. The difference in retarding the action of the lab- 
ferment is due to the increased alkalescence of mother's milk, which 
requires more acid to neutralize the alkali, and thus to render coagu- 
lation possible : hence the greater digestibility of mother's milk. ■ 

Gastric contents containing free hydrochloric acid are bacteri- 
cidal, while combined hydrochloric acid has no such properties. 

Stomach Digestion. — Stomach digestion in the infant divides itself 
into three periods: The first, in which the milk is split by the lab- 
ferment into casein coagulum and soluble albumin; the second, in 
which the stomach contents become acid, having been previously 
neutral or alkaline, and in which chlorine combinations are entered 
into by the casein and lactic acid is formed ; and third, in which the 
above phase of stomach digestion is completed, the contents pass into 
the gut and free hydrochloric acid appears. 

Lab-ferment. — Digestion is thus accomplished by a soluble fer- 
ment, so-called lab-ferment or pexin, which coagulates the casein of 
the milk; a soluble ferment, pepsin, which partly dissolves and pep- 
tonizes this coagulum; and chlorine combinations (HC1), which unite 
the partially peptonized casein, and toward the end of digestion pro- 
duce free hydrochloric acid. Thus the principal changes in the milk, 
so far as the stomach is concerned, occur in connection with the casein. 
As soon as the milk enters the stomach, it is coagulated by the lab- 
ferment, whether its reaction is neutral, alkaline, or acid. This 
casein coagulation depends upon the lab and not upon the acid reac- 
tion of the stomach juice. Lab-ferment is present in the infant's 
stomach as such, and can be demonstrated in the stomach of prema- 
ture and sick infants. Lab-coagulation of the casein is accomplished, 
according to Duclaux, in about fifteen minutes. Part of the casein 
coagulum is acted on by the pepsin and chlorine combinations and is 
converted into absorbable peptones (casease or caseon), the remainder 
passes into the intestine, where digestion is completed by the pan- 
creatic ferments. 

The casein coagulum of cows' and of human-breast milk are essen- 
tially different, the former being a firm mass, containing in its 
meshes the fat of the milk ; the latter being in fine flocculi with little 
of the fat of the milk, and easily acted on by the stomach j uices. In 



DISEASES OF THE STOMACH AND INTESTINES. 



497 



the bottle-fed infant the stomach, half an hour after feeding, still 
contains large coagula, whereas at this time the breast-fed infant's 
stomach contents consist of an easily absorbable homogeneous mass. 
Liquefaction is the work of the pepsin, which is present in the stomach 
juices of the newborn infant, though throughout infancy its action is 
weak and only sufficient to act on the proteids of the milk. Thus, 
half an hour after feeding, albumoses and peptones are found in the 
stomach both of breast-fed and bottle-fed infants. 

Milk Sugar. — Milk sugar is split partly into lactic acid about 
fifteen minutes after feeding, and by the action of lactase (Marfan) 
into glycose and galactose. This view, however, is not accepted by 
all observers, lactic acid not being admitted as normal to the stomach. 
The salts of the milk which have not been precipitated are directly 
absorbed. The fats enter, with the casein coagula, into the gut almost 
entirely unchanged, or a fractional part is saponified by lipase (Mar- 
fan) and absorbed in the stomach. 

In general, it may be stated that in breast-fed infants digestion is 
completed in one and one-half to two hours ; in artificially fed infants 
taking boiled milk in two and one-half to three hours, and in four 
hours in those taking raw milk. 

Bacterial Flora. — The bacterial flora of the infant stomach are as 
yet not fully investigated. So far as known the stomach may con- 
tain the Bacterium coli commune, the Bacterium lactis aerogenes, the 
Bacillus subtilis and the related species, Tyrothrix granulatus and 
Bacillus butyricus of Hueppe, the Bacillus pyocyaneus, the Bac- 
terium lactis aerogenes, the Bacillus megatherium, the Spirillum 
rugula, a leptothrix, Staphylococcus pyogenes, Sarcina ventriculi, 
oidium, hay bacillus, and mould fungi. 

Intestinal Digestion. — The stomach content of the infant as it is 
passed into the intestine consists of unabsorbed water; proteids 
which are made up of casein coagula and in part of syntonin ; albu- 
moses and peptones in combination with chlorides and ammonia ; the 
fatty acids, leucin, tyrosin ; and finally gases, especially carbon diox- 
ide. There are present also the unabsorbed portion of milk sugar 
and a small quantity of lactic acid. The fats pass into the intestine 
for the most part suspended in the watery elements of the milk or 
entrapped in the meshes of the casein coagula. The whole stomach 
content has, as it passes into the intestine, an acid reaction, more 
marked in the artificially fed than in the breast-fed infant. 

The intestinal secretions concerned in the digestion of the above 
stomach content are those of the pancreas, liver, and intestinal wall 
(follicles of Lieberkvihn and Brunner's glands V 

Pancreas.-- This organ is developed at birth, has a weight of 32 
grammes or 1 ounce, and is, therefore, compared with the body- 

32 



498 DISEASES OF THE STOMACH AND INTESTINES. 

weight, much, larger than in the adult. Whereas in the infant the 
pancreas weighs Moo, in the adult it is %oo of the body-weight. 

Ferments. — In the adult pancreatic juice there are three fer- 
ments — trypsin, ptyalin, and a fat-emulsifying ferment, steapsin. 
The infant's pancreatic secretion reveals trypsin and steapsin at birth, 
and even in the foetal state. These ferments are present in small, 
but for the infant's uses sufficient, amounts. There is still a differ- 
ence of opinion as to whether ptyalin is present at all in the pancreatic 
juice of the newborn. According to Karowin, a saccharifying power 
can be detected in the pancreatic juice not earlier than the sixth 
month of infancy, whereas Moro has found traces of such a ferment 
in the pancreas at birth. The fact of its absence or presence in but 
small quantity at birth has been brought forward as an argument 
against the use of amylacea in the food of the artificially fed infant 
at this age. 

Liver. — The formation of bile begins at the third month of foetal 
life, and at birth both bile and glycogen are found to be formed by 
the liver. The bile, which in quantity is comparatively greater at 
birth than in the adult, contains cholesterin, fats, lecithin, mineral 
salts, excepting iron. It contains small quantities of taurocholic 
acid, and but little or no glycocholic acid. It is not strongly anti- 
fermentative at this time. It contains bilirubin and biliverdin, and 
in the young infant urea. Its function in digestion seems to be 
limited to aiding emulsincation of the fats. 

Secretions of the Intestinal Walls. — The intestinal juices secreted 
by the follicles of Lieberkiihn and the glands of Brunner are alkaline 
in reaction, and in the foetus and newborn the ferments, present in 
these juices in the adult, seem to be absent (Miura). The role 
played by these juices in digestion is still a subject for study. 

Digestion — The principal process taking place in intestinal diges- 
tion of the infant is the transformation of the casein of the milk by 
the trypsin of the pancreatic juice into peptone and hemipeptone. 
Part of the casein is rapidly changed into peptone by the pancreatic 
juice, whereas the other portion is acted upon at great length, and 
from hemipeptone changed into absorbable substances which, partly 
crystalline, are taken up by the mucous membrane of the gut and 
synthetically transformed into albumins. 

In the breast-fed infant the casein flocculi are digested and dis- 
solved in the duodenum, and the contents of this portion of the gut 
are slightly acid. In bottle-fed infants the digestion and solution of 
the casein is less complete in the duodenum than in the breast-fed 
infant, and the reaction of the contents of this portion of the intestine 
is distinctly acid. 

Milk Sugar. — The milk sugar is split in the gut into galactase 



DISEASES OF TEE STOMACH AND INTESTINES. 400 

and dextrose and thus absorbed. This is accomplished, according to 
Marfan, by the lactase of the intestinal juices. 

Fats. — The fats of the milk pass from the stomach into the duo- 
denum but little changed. They are suspended in the watery element 
of the milk or entrapped in the meshes of the casein flocculi or coagula. 
The fats are partly emulsified and in part split up by the pancreatic 
juice into fatty acids and glycerin, and in these forms absorbed by 
the intestinal villi. The digestion and absorption of the fats, how- 
ever, is incomplete in the intestine of the infant, and much of it is 
excreted in the fseces in the form of neutral fats and fatty acids. 

In the healthy breast-fed infant most of the above digestive trans- 
formation is completed in the duodenum and the products are absorbed 
in the upper part of the small intestine. This is especially true of 
the casein or proteids, of which only traces are found in the lower 
portion of the small intestine. 

Intestinal Residue. — After the absorption of the nutritive portion 
of the intestinal mess, the contents of the intestine consist of biliary 
remains, amido-acids, various products of bacterial fermentation, 
acids, and soaps, which are in part taken up and transformed by the 
liver and in part excreted. In addition, there are neutral fats and 
fatty acids. The minute quantity of proteids which has escaped 
digestion and solution and has not been absorbed is transformed by 
the bacterial flora of the gut into the products of decomposition, and 
as such are found as indol, skatol, phenols, and ammonia in the fseces. 
These also are in part taken up by the liver and in part excreted. 
The processes of decomposition, which are quite limited in the breast- 
fed and marked in the artificially fed infant, reach their highest 
development in the colon. 

Characteristics of the Stools of Normal Infants. — It may be 
stated that the movements of bottle-fed differ from those of breast-fed 
infants in that they are lighter in color and in the main more bulky. 
In the perfectly normal breast-fed infant the stools may at times vary 
in color and general consistence ; thus we can scarcely speak of a 
uniformly normal movement. Gregor has accounted for this by 
assuming that the stool of the infant at the breast may vary because 
of the composition of the breast-milk from day to day and at different 
hours of the day. Inasmuch as the percentage of fat in breast milk 
varies so widely, the appearance of the stool will vary likewise. In- 
fants fed on cows' milk and carbohydrates will have movements resem- 
bling those of breast-fed infants. 

If a number of normal infants are observed, it will be seen that 
from time to time even the breast-fed infant will present movements 
the consistence of which is more or less watery, and which contain 
coarse white curds and particles without any disturbance of the fane- 



500 DISEASES OF THE STOMACH AND INTESTINES. 

lions of the gut. Moreover, the amount of water contained in a 
normal movement is considerably more so than would appear from 
its ordinary putty-like consistence on the diaper (Czerny). Infants 
taking a malted food will present movements that are dry and broken 
up into crumbs, and which have a distinct odor of malt. The move- 
ment of breast-fed babies and those fed upon carbohydrates and fatty 
food are softer than those of babies fed upon cows' milk exclusively. 
The movements of infants fed on cows' milk exclusively are lighter 
in color than those of the breast-fed child. 

In general the faeces of infants may be said to contain digested 
absorbable substances, undigestible substances, digested products of 
digestion and decomposition, anatomical elements of the digestive 
organs of the stomach and gut, mucus elements, and bacteria. If 
the movements of the breast-fed infants are closely examined, they 
are found to contain small whitish curd particles, the milk granules 
of UfTelmann. These were at first thought to be composed of casein : 
it is now known that they are made up of fat-crystals, and zoogloea 
of bacteria. Talbot has lately demonstrated that, in addition to fat 
and soap crystals, these curds contain nitrogen. In addition, there 
are found in the fasces of infants epithelial elements, bilirubin crys- 
tals, and cholesterin plates. Fat appears in the faeces of infants 
rarely as fat crystals, but generally as fatty acids, neutral fats, and 
soaps. 

The movements of infants fed on a mixed diet contain free starch- 
granules, cellulose, and also cholesterin plates and bilirubin ; the prod- 
ucts of decomposition — indol, skatol, and phenol — are also found, 
according to. the time which has elapsed since the voidance of the 
movements (Blauberg). Sugar is not found in the fasces of infants, 
or only in small quantities (UfTelmann and Blauberg). Michael has 
found that the gross weight of fasces in the newborn breast-fed infant 
was about 1.5 per cent, of the gross amount of food ingested; while 
later in infancy the movements were 2.7 per cent, of the amount of 
food ingested. Rubner and Heubner found that in bottle-fed infants 
the fasces were about 4.7 per cent, of the amount of food ingested. 
Michael found that the fasces in the first days of infant life contained 
about 72 per cent, of water, while in the ninth month of infancy they 
contained 85 per cent. 

Reaction of the Stools. — The reaction of the stools of infants, both 
breast- and bottle-fed, has been the subject of much discussion, because 
of the difference of opinion among investigators as to what constitutes 
a normal movement in an infant. It may be stated, however, that 
the stool of the breast-fed infant is regularly acid in reaction and has 
an acid odor even after being passed for some time. The infant fed 
upon cows' milk has a stool which is alkaline in reaction, sometimes 



DISEASES OF THE STOMACH AND INTESTINES. 



501 



neutral, and, under certain conditions which no longer may be looked 
upon as absolutely normal, slightly acid. The stools of these infants 
have an odor more or less recalling that of stale cheese ; in other words, 
an odor of decomposition. 

The Daily Number of Movements. — The normal infant, whether on 
the breast or the bottle, will have one, two, or even three movements 
daily when in perfect health. In the breast-fed infants these move- 
ments may be small or large and even contain quite an amount of 
fluid and still be within the limits of health. In the bottle-fed in- 
fants, however, the stools are, as a rule, larger in bulk than those of 
the breast-fed infants, and contain less water. I have seen bottle-fed 
infants in perfect health who have had as many as four movements 
daily, all having normal characteristics. Infants may have six 
movements daily and still be in perfect health. If the consistence 
and color are within normal limits, the number simply indicates the 
amount of intestinal residue, and not disease. 

Bacterial Flora Within two or three days after birth the meco- 
nium changes its characteristics and assumes those of milk faeces. 
In the milk faeces of the infant nursed at the breast we find as 
predominant, first, a bacillus described by Tissier, which stains 
with Gram's stain, and which in the crude specimen seems to occupy 
most of the microscopic field. This is called the Bacillus bifidus 
communis. It is an anaerobe. In addition to this bacillus, we find 
next in numbers the so-called Bacillus acidophilus of Moro and Fink- 
elstein. The latter also stains with the Gram stain. In addition to 
these two bacilli, which are found in greatest numbers in the faeces 
of the breast-fed infant, we have a few coli bacilli, and also some 
numbers of the Bacillus lactis aerogenes. 

The faeces of the infant fed on cows' milk present a much more 
luxuriant flora of bacteria than those of the breast-fed infant. There 
are: (1) the Bacillus coli communis, (2) the Bacillus acidophilus in 
small numbers, (3) other Gram-staining bacilli, (4) the Micrococcus 
ovalis (Escherich and Tissier), (5) the enterococcus of Thiercelin. 
(6) a diplococcus staining with Gram, (7) streptococci and staphylo- 
cocci, (8) Sarcina minuta, (9) the Bacillus lactis aerogenes. The 
Bacillus lactis aerogenes splits milk sugar into lactic acid, carbonic 
acid, and water, and causes the intestinal contents to become acid. 
In the lower part of the gut we find the Bacillus coli communis, a 
micro-organism which may exist in the presence of any reaction, ami 
which splits milk sugar into lactic acid, carbonic acid, ami water, and 
partly splits fat into fatty acids. It is the prevalent micro organism 
in the stools, though with it we have a number o( the Bacillus lactis 
aerogenes, a yellow fluorescent or fluidifying coccus, three fluidifying 
cocci, a Micrococcus ovalis, a porcelain coccus, the tetrad coccus, the 



502 DISEASES OF THE STOMACH AND INTESTINES. 

white and red hay bacillus, a capsule bacillus, the Monilia Candida, 
all of which exist in varying numbers. 

Acute Gastric Dyspepsia (Indigestion). — Acute gastric dyspep- 
sia may clinically be divided into two forms, that affecting infants, 
either at the breast or bottle, and that affecting older children. The 
period of infancy is one of frequent disturbances. Mental excite- 
ment on the part of the nurse may cause the milk to disagree with a 
breast-fed infant. The ingestion of an undue quantity of breast- 
milk, even if of good quality, may cause indigestion. Certain articles 
of food, if partaken of by the mother, may cause gastric irritation. 
Nursing a breast in which the milk has caked will also cause indi- 
gestion. 

Symptoms. — Vomiting is the first evidence of disturbance of the 
digestive processes in the infant. It occurs after feeding, and is at 
first not accompanied by constitutional symptoms or diarrhoea. If 
the exciting cause continues, a slight febrile movement is noted, and 
also slight prostration. The infant is restless, but having vomited is 
relieved, and if permitted will again take the breast, or bottle, the 
vomiting taking place after each nursing. The bowel movements 
then become disturbed. They may not only be green, but also frequent 
and in some cases fluid. There are in all cases colic and tympanites. 

Acute gastric dyspepsia in older children may be caused by some 
article of diet which has disagreed with the patient. The symptoms 
are much the same as those seen later in life. It is important both 
with infants and children to determine whether the symptoms are 
due to improper food or whether proper food has for some reason dis- 
agreed. Bottle-fed infants are liable to indigestion if the milk con- 
tains any extraneous substances, not necessarily toxic ones. 

A baby may have thrived for weeks on a certain food-mixture, 
when suddenly, without apparent cause, symptoms of gastric dyspep- 
sia supervene. In such cases it will be found that the acidity of the 
milk was greater than usual, or that the fodder of the cows furnishing 
the milk has been changed. In some cases the infant, whether on 
the breast or bottle, will spit up curds of an exceedingly acid nature 
or vomit a watery acid substance after feeding. 

Course. — If the food is suspended and proper treatment instituted, 
the symptoms subside and the infant recovers, but if the exciting 
cause is not removed, more serious disturbance of the stomach and 
gut will develop. 

Treatment. — It is best both with breast-fed and bottle-fed infants 
to discontinue the giving of all food as soon as symptoms of indiges- 
tion appear. With the suspension of food the administration of a 
simple cathartic (castor oil) is all that is necessary. The infant is 
put for twelve hours on a solution of white of egg, and the breast 



DISEASES OF THE STOMACH AND INTESTINES. 



503 



pumped regularly every three hours to prevent caking. The breast 
may then be cautiously exhibited. Stomach washing should not be 
resorted to, and the breast should not be denied for too long a period. 
If, on resuming breast-feeding, symptoms reappear, an analysis; of 
the milk should be made. Its composition may have changed and 
too much fat may be present. We should not be hasty in taking an 
infant from the breast and placing it on the bottle on account of a 
few symptoms of gastric dyspepsia. Proper regulation of the diet 
and the taking of proper exercise by the nurse will frequently cause 
the desired adjustment of the constituents of the milk and the disap- 
pearance of symptoms. 

Habitual Vomiting of Infants. — Habitual vomiting of infants 
refers to the regurgitation of milk in the uncoagulated state shortly 
after nursing. It occurs in infants in apparently good health, and 
is not followed by loss of weight or disturbance in the functions of the 
gut. Some infants vomit curdled milk in the same manner. The 
cause of this form of vomiting has been variously explained. The 
simplest explanation is, that by slight pressure the food is forced into 
the oesophagus and thence reaches the mouth. It is a well-known fact 
that the stomach of the infant can be emptied by gentle abdominal 
pressure. Another explanation is that on deep inspiration the nega- 
tive pressure caused by descent of the diaphragm forces a certain 
amount of fluid from the stomach, which is almost vertical in the 
infant, into the oesophagus and thence into the mouth. This form of 
vomiting requires no treatment. The general impression is that it 
can be stopped by regulating the amount of breast-feeding, but this 
belief is erroneous, as the vomiting persists after such precautions 
have been adopted. Fleischman thinks that the habit is hereditary 
in certain families. 

Cyclic Vomiting (Periodic vomiting; Recurrent vomiting), — 
Definition.- — Cyclic vomiting is a condition in which there appear at 
intervals more or less remote from each other attacks of vomiting, 
accompanied by marked prostration without rise of temperature, in 
which there is an absolute intolerance of the stomach for even fluid 
food. This condition has been described under various headings 
both in France, 1841, by Dr. Gruere; by Lombare, in 1861; in 
England by Gee, and in America by Eotch, Holt, Rachford, Edsall, 
Koplik, and others. 

Etiology. — The etiology of this condition is obscure, % and ii is most 
probable that the theory of Rachford is correct — that the symptom- 
complex is one of gastro-intestinal lithsemia, due to an increased 
acidity of the fluids o( the UhIy as the result o\ disturbed metabolism. 
In one of these cases Eerter has analyzed the amount of uric acid in 
the periods preceding, during, and following the attack. In such an 



504 DISEASES OF THE STOMACH AND INTESTINES. 

analysis the gross amount of uric acid was greatest on the second day 
of the disease, and fell rapidly on the third day to near the normal. 
The normal relation of uric acid to urea in these patients was as 1 : 54. 
During the attack the relation of uric acid to urea, as a rule, was 
1 : 85, and in the normal condition it fell to 1 : 42. Griffith considers 
the condition a species of toxsemia. 

It seems to me, from a study of a number of my own cases, that 
the condition described by Eachford must obtain; in addition, how- 
ever, these are crises in which the patients seem to suffer distinctly 
from attacks of intestinal intoxication, inasmuch as treatment directed 
toward placing the conditions in the gut on a normal basis seems to 
benefit them materially. In most of my own cases there has been a 
history of constipation extending over long periods of time, and an 
intolerance of milk as the main article of diet in other cases. 

Other observers (Holt) have not found constipation to be a promi- 
nent factor in their cases, but rather that the ingestion of certain 
forms of foods, such as amylacea, are apt to precipitate an attack. In 
only one of my cases have I found that amylacea were badly borne, 
and the ingestion in this case of a cereal gruel seemed to precipitate 
an attack ; constipation, however, existed in this case from infancy. 

Symptoms. — The symptoms in these cases are quite characteristic ; 
the subjects of this form of disturbance may be well developed, but, 
as a rule, they are pale. In some of them the anaemia is quite 
marked, and the children have a pasty complexion. The attack is 
preceded by a period during which the child complains of slight pain 
in the stomach ; in some cases this may be absent. The child awakens 
in the morning, feels tired, has no appetite for breakfast, and has 
pronounced pallor. Vomiting sets in; the food is first rejected and 
then vomiting persists ; in some cases even blood with mucus is vom- 
ited from the stomach. In other cases the contents of the duodenum 
may appear in the vomitus in the form of biliary matter. The child 
finds most comfort in lying quietly on its back, refusing to take any 
food; even water is vomited. There is no temperature; there may 
be a slight increase of the pulse-rate, and it may have a bounding 
character, and the heart-impulse may be increased in force. There 
may be a complaint of epigastric pain. The prostration in some cases 
is extreme ; the condition may last twenty-four hours to two or three 
days, until normal conditions are established. The vomiting may 
recur several times in twenty-four hours; it gradually diminishes in 
frequency and disappears. During this time there is no movement 
from the bowels, or there may be a constipated movement as the result 
of enemata, with the voidance of a large quantity of mucus. The 
stools have an exceedingly offensive odor. The following is a char- 
acteristic case: 



DISEASES OF THE STOMACH AND INTESTINES. 



505 



Dorothy E., five years of age, fed in infancy on modified milk; 
has never suffered from any disease of greater severity than a grippal 
attack. She has been constipated since infancy, and this constipa- 
tion has lately become more marked. After having been put on raw 
milk and cream, the constipation abated for a few weeks and then 
returned. The constipation was only relieved by the constant use 
of cathartics, and sometimes these were not effective. The child is a 
well-developed girl, thirty-five pounds in weight, with a body-length 
of 102 cm. (3 feet 4 inches) ; the abdomen is protuberant; there is 
no disease of the heart or lungs ; the liver and spleen are normal in 
size. The urine does not contain albumin or casts. The child is 
ansemic, has a tired expression, and her intestinal movements contain 
considerable mucus. Her vomiting attacks began when she was four 
years of age. These attacks last two or three days, during which the 
child rejects all food. The attacks begin very much in the manner 
just described. In one of these attacks the vomiting was so severe 
that there was an alarming hemorrhage from the stomach. The odor 
of the breath in the first day of the attack is " sweetish " (acetone). 

Some of my cases during the attacks presented albumin and a 
few hyaline casts in the urine. These disappeared after subsidence 
of the attack. Acetone bodies may be present in the urine in in- 
creased quantity, or they may be absent. 

Diagnosis. — The practitioner should be exceedingly cautious when 
presented with a case of vomiting in a child from four to five years 
of age not to hastily conclude that it is one of cyclic vomiting before 
making a thorough examination, not only of the urine, but of the 
other viscera. 

A case has recently come under my notice, observed for four years, 
in which a diagnosis was made of cyclic vomiting, but which is one 
distinctly of nephritis with recurrent attacks of uraemia. Other 
cases may be masked appendical attacks. 

Some authors, such as Rotch, have laid stress on the fact that these 
attacks may also simulate meningitis. 

Course and Prognosis. — The prognosis in this condition, so far as 
life is concerned, is good. There are some cases recorded which have 
terminated fatally. The course of the disease, if properly handled, 
ends, as a rule, in recovery in from twenty-four hours to three or 
four days. 

Treatment. — The treatment of cyclic vomiting is divided into the 
treatment of the attack and the intervals between the attacks. 

The Attack. — The patient is put to bed, kepi perfectly quiet, and 
little or no fluid is given by the stomach- — certainly no solid food. 
The stomach is quieted with small doses o\' codeia. This is the only 
remedy which in my hands seems to have had any influence in con- 



506 DISEASES OF THE STOMACH AND INTESTINES. 

trolling prolonged vomiting. Enemata consisting of saline solution 
are given twice daily. They should be high enemata, and at least a 
quart of water should be thrown into the rectum at each sitting. In 
the intervals between the enemata the child should be nourished by 
the rectum. Somatose solution — 1 drachm of somatose to 8 ounces 
of cold water — is heated to a lukewarm temperature, and given by 
the rectum in quantities varying from 2 to 4 ounces every three 
hours. The patient is given small pieces of ice to swallow, in the 
case of older children. ~No other treatment is necessary until the 
attacks of vomiting subside of their own accord within twenty-four 
hours. It is surprising to see how comfortable these little patients 
will be if little or no fluid is taken by the mouth; in fact, some of 
them are intelligent enough to find this out for themselves and refuse 
all nourishment. On the second day of the disease, when the vomit- 
ing has subsided to a great extent, we may give the patient broths, 
fruit juices, diluted gruels; and on the third day we may gradually 
return, if the stomach is tolerant, to a semi-solid diet, and finally to 
a full diet. As soon as the stomach is tolerant of fluids, and even at 
the height of the attack, small quantities of Vichy given by the 
stomach seem to be grateful to the patient. During this period also 
the alkaline treatment, which will be spoken of, may be inaugurated ; 
and finally we may, toward the close of the attack, if this is possible, 
give a vigorous cathartic, such as cascara, or Rochelle salts. 

The Intervals. — In the intervals between the attacks these patients 
do best on the following treatment : The bowels should be kept in a 
normal condition; if the child is constipated a rectal enema should 
be given daily, and, if this is not effective, it should be supplemented 
by some cathartic, such as cascara, in order to facilitate a complete 
daily evacuation of the bowel. The diet in these children should be 
a mixed one. I have found that whereas some of these children will 
not tolerate cereals, others will. The rule, however, is that we should 
reduce the quantity of milk, especially in the older children, to a 
minimum, and, if possible, place the patient on a diet in which milk 
enters but little. They should be placed, so far as medicinal agents 
are concerned, on the so-called alkaline treatment, which has been 
found to be most successful in these cases. For a child from three 
to five years of age I prescribe a powder composed of 2 to 3 grains 
of bicarbonate of soda and \ to \ grain of carbonate of lithium. This 
powder is given three times daily after meals in a glass of Vichy 
Celestins. The children are bathed daily in a bath in which a hand- 
ful of bicarbonate of soda and a handful of salt have been dissolved, 
and are rubbed down after the bath with a very dilute solution of 
alcohol in water and a rough towel. The muscles of the body are 
kneaded, if a masseuse is available. Sojourn in the open air as 



DISEASES OF TEE STOMACH AND INTESTINES, 507 

much, as possible is advised, arid sports whieh involve muscular exer- 
tion encouraged. Regularity at meals is inculcated, and these little 
ones are taught, if possible, to evacuate the bowel regularly. In 
some of these cases the coarser the diet, the more successful seems to 
be the treatment, for in the most aggravated eases that I have seen 
there has been a too " finicky " selection of a few articles of diet for 
these patients, and the little ones have been kept in some cases on 
milk, gruels, and fruits, to the exclusion of everything else, for 
months. 

Other Forms of Vomiting. — There are other forms of vomiting 
which are of interest in this connection : 

a. Some children vomit when irritated or after outbursts of tem- 
per, or may vomit at will if their food or anything in connection with 
their discipline does not meet their approval. Some of the little 
patients know intuitively that vomiting alarms the mother, conse- 
quently it will appear whenever any concession is to be obtained in 
the nursery. 

b. Vomiting, especially after eating, may be caused by a severe 
attack of coughing. If vomiting occurs frequently under these con- 
ditions, whooping-cough should be suspected. 

c. The vomiting of pyloric stenosis of the congenital type is char- 
acteristic. It is more in the nature of a regurgitation. When lying 
on the back the baby vomits at intervals, and in small quantities. 
After a nursing there is an interval, after which the infant vomits 
two or three times the amount of food taken at the recent nursing. 
This is explained by the fact that in this condition there is some little 
vomiting constantly going on, due to the increased peristalsis of the 
stomach. There is, however, a small quantity of food retained in the 
stomach. This residual quantity increases with each feeding, and is 
finally rejected in the manner just described. 

d. The vomiting of appendicitis is also characteristic. The pa- 
tient is seized suddenly with sharp abdominal pain and then begins to 
vomit. The vomiting may recur once or twice, and then eease. In 
neglected cases, in the final agonal stage, vomiting due to sepsis and 
toxaemia may be persistent. 

e. Vomiting is the first symptom in intestinal obstruction. It 
may be followed by a very small movement, and then for a short 
time there is, as a rule, no action on the part of the bowels. The 
vomiting may not recur in the first twenty-four or forty-eight hours. 
except at long intervals, but the bloody movements recur frequently, 
and pain is also present. The vomiting returns when the intussus- 
ception is more marked, ami late in the affection becomes faecal, 

f. Vomiting occurs at the outsel of the infectious diseases. Per- 



508 DISEASES OF THE STOMACH AND INTESTINES. 

sistent vomiting extending over a period of months is often of 
nephritic origin. 

g. The vomiting which accompanies meningitis occurs at the out- 
set in that disease, and is quickly followed by cerebral symptoms. 
In tuberculous meningitis it occurs at the onset and after the appear- 
ance of a vague series of cerebral symptoms. It is rarely persistent 
after the initial attack. The subsidence of the vomiting and the 
sequence of cerebral symptoms and a febrile movement will easily 
distinguish this form of vomiting from others. 

Tumors and abscess of the brain are accompanied by vomiting at 
intervals. There is in these and in all cerebral cases persistent, severe 
localized headache. 

Colic. — Colic is not a disease, but a symptom of disturbed con- 
ditions in the intestine. It is really a painful contraction of the 
muscle-fibre of portions of the intestine. In the simplest form the 
painful contractions are incited by actual distention of the lumen of 
the intestine. The pain caused in colic is in the majority of cases 
not of the character which arises in certain other affections of the 
intestine which are neurotic in nature, nor is it of the same nature 
as that seen in enteritis. Pain similar to that in colic may be caused 
by the administration of some such drug as lead, arsenic, etc. 

Cause. — In the great majority of cases the affection is caused by 
some disturbance of the processes of assimilation. It is uncommon 
in infants in good condition, and its appearance in any case indi- 
cates the necessity of a study into the condition of the digestive 
processes in the stomach and intestine. The form of pain or colic 
accompanied, by distention (tympanites) seen in newborn infants, 
and also at the height of pneumonia in older children, has an etiology 
distinct from that of the ordinary variety. Not only is the pain 
of neurotic origin, but also the distention is a result of paralysis of 
the muscular fibre of the intestine. The intestinal processes may be 
disturbed as a result of the pneumonia. Colic may occur in breast- 
fed or in artificially fed infants. In the former it is not always pos- 
sible to discover the exact cause. The breast milk may be abundant, 
of good color, and of correct composition, and still there may be very 
violent colicky pains. In artificially fed infants the cause of the 
colic may lie in the very nature of the food (cows' milk) and the diffi- 
culty of complete assimilation. Thus an excess of fats in the milk 
cause colic. 

Symptoms. — An attack of colic is preceded by general uneasiness ; 
the infant cries and cannot be quieted. The severe colicky pain is 
accompanied by sharp cries, the arms and lower extremities are drawn 
up, and the abdomen is rigid. After the passing of gas the infant 
is quieted and falls asleep quite exhausted. These attacks of colic 



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DISEASES OF THE STOMACH AND INTESTINES. 



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deprive the infant of sleep ; they may or may not be accompanied by 
tympanites. The movements are rarely normal, or may be normal 
for some days and then take on a curdy character or become greenish. 
Sometimes the colicky attacks are accompanied by a mild form of 
diarrhoea ; the pain may be so severe as to cause convulsions. 

Treatment. — See below under Tympanites. 

Tympanites. — Tympanites is a condition of distention of the in- 
testine with gas, which may supervene in inflammatory states of the 
peritoneum. In such conditions (peritonitis, appendicitis) the paral- 
ysis of the muscular wall of the intestine is the real cause of the dis- 
tention. In other states, such as pneumonia, it may be the result of 
inefficient action of the diaphragm in not expelling the intestinal 
gases and of an enteric catarrh which sometimes accompanies that 
disease. In the newborn infant, tympanites is a result of an inherent 
muscular weakness of the intestinal wall. In colic due to imperfect 
assimilative processes, the tympanites is due to the formation of gases 
of which the intestine is unable to rid itself rapidly (Plate XXVIII. ). 

In pneumonia the tympanitic distention is sometimes extreme, 
causes great distress, and is frequently mistaken for peritonitis. In 
the forms of distention in the newborn infant the distress is not so 
great. In rachitis there is a state of tympanitic distention of the 
abdomen due not only to defective assimilative processes, but also to 
a lax condition of the muscle-fibre of the intestinal walls. 

Treatment of Colic and Tympanites. — If the food of a bottle-fed 
infant is at fault, the modification of milk must be altered so that the 
proportion of the fats may be lower. A reduction of fat will not 
always remedy the condition; the proportion of sugar is sometimes 
at fault, especially in infants fed on condensed milk. Not more than 
6 per cent, of sugar should be added to any milk modification. Some 
infants can take a large quantity of malt-sugar in their food and not 
suffer from colic. If a breast-fed infant suffers from colic, the 
hygiene of the nurse should be attended to. If after the taking of 
exercise and regulation of diet the colic persists and becomes a fea- 
ture in the case, the wet-nurse should be changed. 

The attack of colic is best combated by giving the infant an 
enema. In some cases a small amount of dilute hydrochloric acid 
and pepsin given three times daily will alleviate the symptoms. In 
other cases a small dose of pancreatic extract and bicarbonate of 
soda will, after feeding, succeed in alleviating symptoms. If in 
spite of all efforts an artificially fed baby suffers with colic and does 
not increase regularly in weight, it should be placed ai the breast. 

Dilatation of the Stomach. Etiology. — Dilatation of the stomach 
may be due to mechanical causes, such as stenosis o\' the pylorus, 
resulting in oven-tilling of the stomach, with consequent dilatation: or 



510 DISEASES OF THE STOMACH AND INTESTINES. 

it may be caused by muscular atony, such as is present in general 
atrophy or rachitis. In mechanical stenosis of the pylorus the mus- 
cular structures are intact at first ; hypertrophy subsequently appears 
in the region of the pylorus, with secondary dilatation of the fundus 
of the stomach. An hour-glass distortion of the form of the stomach 
and, subsequent to this, a sausage-shaped dilatation of the organ 
result, the long diameter of the dilatation being in the long axis of 
the stomach. This last-named deformity is permanent. 

The location of a dilated stomach in the child differs somewhat 
from that in the adult. The pylorus in the child lies deepest and 
near the umbilicus in the mid-line ; the fundus lies transversely across 
the abdomen at the situation of the umbilicus ; whereas in the vicinity 
of the border of the ribs it passes abruptly upward. The muscular 
coat of the stomach in these cases is thin and atrophic. If there is 
overloading of the stomach, or the ingestion of indigestible sub- 
stances, the organ is not thoroughly emptied, and as a result there are 
fermentation and accumulation of food in the stomach. Muscular 
relaxation results, and then atrophy of an otherwise weak muscula- 
ture. In arthrepsia and rachitis the musculature of the stomach is 
primarily weak, and repeated attacks of dyspepsia with overloading 
result in dilatation. 

Symptoms. — The symptoms of dilatation of the stomach as a result 
of pyloric stenosis are described elsewhere. As a result of chronic 
dyspepsia and overloading of the stomach in younger children there 
are at first the ordinary symptoms of evanescent dyspepsia. There is 
vomiting after meals, and after a time this vomiting takes place after 
the food has accumulated in the stomach. With the attacks of vom- 
iting there is loss of appetite, and finally an intolerance of all food, 
even in very small quantities. Constipation follows as a result of 
lack of appetite and the avoidance of food. Meteorism is present in 
some of these cases; whereas in others intestinal catarrh may alternate 
with the constipation. 

In older children dilatation of the stomach results from repeated 
attacks of dyspepsia which extend over months. The development 
of the disease is slow. There are loss of appetite, a feeling of ten- 
sion and overloading after meals ; the odor of the breath is bad ; the 
tongue is coated ; children complain of headaches ; the bowels are very 
irregular, sometimes constipated; and finally vomiting after meals 
sets in. The vomited matter contains not only particles of food, but 
sarcinse and other species of bacteria. The reaction of the stomach- 
contents may be neutral or acid, the hydrochloric acid and propeptone 
may be increased or may vary on different days ; lactic, butyric, and 
acetic acids may be present in the vomited matter as a result of 
fermentation. 



DISEASES OF THE STOMACH AND INTESTINES. 5 1 1 

Physical Signs. — The physical signs consist of persistent meteor- 
ism and tympanites. The abdomen is very much enlarged, and in 
some cases the stomach can be distinctly outlined, especially the 
greater curvature. If the child is examined lying on its back, with 
its knees raised and the pelvis supported with one hand while the 
other taps the abdomen sharply over the situation of the stomach, the 
distended organ will yield a so-called succussion sound, due to accu- 
mulated contents in the organ. In many cases a dilated colon may 
be mistaken for a dilated stomach. By means of gastrodiaphany the 
author has been able to mark out quite distinctly the greater curva- 
ture of the stomach. 

Prognosis. — The prognosis will vary according to the exciting 
cause. If the dilatation of the stomach is caused by congenital 
stenosis of the pylorus the prognosis is doubtful ; if caused by repeated 
attacks of gastric dyspepsia the prognosis is more favorable. It is 
not as favorable in severely rachitic children, in whom there may be 
at the same time a progressive atrophy of the muscular tissue of the 
stomach. 

Treatment. — The treatment of dilatation of the stomach in infants 
and children does not differ materially from the treatment of the 
same condition in the adult. In infants the quantity of solid food 
and fluids given at each meal is reduced to a minimum. The sys- 
tematic washing of the stomach at intervals is indicated in these cases, 
as in older children and adults. With older children the amount of 
fluids is also limited. Soups are excluded and milk is peptonized. 
Bread, meat, and digestible substances are preferred to fluids. In 
these cases also the stomach is washed systematically. 

The medical treatment of these cases consists in the administra- 
tion of hydrochloric acid, pepsin, general hygiene, massage, faradiza- 
tion of the stomach in severe cases, as in the adult. 

Ulcer of the Stomach. — Ulcer of the stomach may occur as a 
complication in sepsis of the newborn, in acute gastritis, and in tuber- 
culosis. As a primary disease, this affection is very rare in infancy 
and childhood, although cases are reported in the literature as a com- 
plication of infectious diseases, such as scarlet fever, typhoid fever, 
measles, tuberculosis. Reimer records a case in a child three and a 
half years of age. Hibbard met a case in an infant four months of 
age. Rotch reports a case in an infant seven weeks old. It is rare. 
however, between the ages of one and ten years. In 226 autopsies 
Brinton saw it twice. I have seen it at an autopsy in a ease of em- 
pyema. It occurs in chlorotic girls toward the age of puberty, and 
is not essentially a disease of infancy and childhood. 

Congenital Pyloric Spasm and Congenital Hypertrophic Stenosis 
of the Pylorus {Congenital Stenosis of the Pylorus; Congenital 






512 DISEASES OF THE STOMACH AND INTESTINES. 

Hypertrophy of the Pylorus and Stomach-ivall; Congenital Gastric 
Spasm). — Hypertrophic pyloric stenosis is a congenital condition 
which appears from a few days to several weeks (three months) after 
birth, and manifests itself in persistent vomiting. In a few instances 
several infants in the same family have been thus affected. 

The first case of pyloric stenosis was described by Dr. Beardsley 
in the Transactions of the New Haven Medical Society (Osier). 

Landerer (1879), Maier (1885), and Hirschsprung (1887) re- 
opened the study of this affection. 

Etiology. — The etiology of the affection is obscure. Since in the 
majority of the cases which have been carefully studied the infants 
were overfed or improperly fed, it is supposed that some irritant to 
the stomach is the exciting cause. Thomson, who has made careful 
studies of these cases, believes that the condition originates in intra- 
uterine life, and is due to the ingestion of liquor amnii. This fluid, 
by irritating the mucous membrane of the stomach, excites both that 
organ and the pylorus to overaction. Pf aundler denies that there is 
a true hypertrophy of the pylorus, and asserts that the condition 
during life is that of functional spasm. The postmortem condition 
is due to toxic agonal contracture of the pylorus. 

Another theory is that congenitally there may be some narrowing 
of the orifice of the pylorus, but not sufficient to prevent the passage 
of food. Such infants are immediately after birth in apparent 
health and only later the spasm amounting to a real stenosis of the 
pylorus makes its appearance, due to an increased acidity of the con- 
tents of the stomach reacting on a sensitive mucous membrane and 
causing a spasm of the already impaired sphincter. This acidity is 
supposed to be due to improper feeding or excess of some element of 
the food such as fat. 

Morbid Anatomy. — The stomach and oesophagus have been found 
to be dilated in fully one-third of the reported cases. The mucous 
membrane shows the usual change, such as the congestion which is 
seen in a stomach in which there have been functional disturbances. 
The mucous membrane of the pylorus is thrown into voluminous folds. 
The lumen has in some cases been found patent to a small probe, but 
fluids cannot be forced from the stomach through the pylorus (Thom- 
son). The muscular fibres show characteristic change. The circular 
fibres are thickened and hypertrophied (Thomson). In Finkelstein's 
case the longitudinal fibres were also thus affected. Some deny this 
hypertrophy and contend that it is an agonal contraction. 

Classes of Cases. — To my mind there are two distinct sets of cases 
which give rise to symptoms to be detailed. In one set there is a dis- 
tinct spasm of the pylorus and stomach without any marked hyper- 
trophy and with a limited amount perhaps of stenosis of the pylorus. 



DISEASES OF THE STOMACH AND INTESTINES. 513 






After a time such cases improve and eventually recover, leaving no 
trace of the illness in the patient. 

In the other set there is a congenital condition of marked stenosis 
of the lumen of the pylorus and to this there is superadded a spasm 
which causes this lumen to "become completely obstructed. To this 
is added a marked hypertrophy of the muscular fibres which enter 
into the structure of the pylorus. The mucous membrane and mus- 
cular coats are thickened and thrown into obstructing folds of tissue. 
In a great many instances this condition admits of improvement. 
The spasm relaxes, the lumen of the pylorus opens up and, though it 
may remain narrowed, under correct diet the patient improves and 
increases in weight. I have published such cases as well as cases 
illustrating the purely spastic condition of the pyloric orifice. 

Symptoms. — Infants in whom this condition is present are of 
normal weight and appearance when born. The great majority of 
them have been breast-fed ; I should say from the literature that fully 
two-thirds of the children were breast-fed from the start. After a 
while, varying from one to four days, in other cases seven days, and 
in a great many cases the third week after birth, in exceptional cases 
the eighth week after birth, the vomiting begins. In a few cases, as 
in some of my own, there is a history that an attempt was made to 
feed the baby, in addition to the breast, on the bottle, and in these 
cases the vomiting began from the attempts at mixed feeding. In 
other cases there is no such history, the mother's milk being the only 
food ; the milk seemed to be abundant, and there was no change in the 
milk or in the mother to account for the disturbance in the child. 

The vomiting occurs at first at intervals throughout the twenty- 
four hours, and soon becomes persistent, the child rejecting sometimes 
a portion or all of every nursing. Sometimes the history will show 
that the infant has rejected more than it had taken. This is quite 
characteristic, and points toward a retention in the stomach of some 
of the previous feedings. With the vomiting there is a steady ema- 
ciation or a stationary weight. If the weight is stationary, the 
patient is fortunate. If the emaciation is progressive, in a few 
weeks an infant which had been perfectly well at birth, weighing the 
normal or above the normal, is reduced to a distinctly marantic con- 
dition. With the vomiting there are other signs of constitutional 
disturbance. 

It seems that every time the breast is given to the child, or within 
a few minutes after nursing, there are evidences in some cases 6i 
pain; the children will cry and this will be told to the physician by 
the mother. In addition there is constipation in most eases, or the 
movements are small, minimal in quantity, sometimes fluid in con- 

33 



514 DISEASES OF THE STOMACH AND INTESTINES. 

sistency, or they may be greenish. As a rule, the movements indi- 
cate that very little has passed through the gut. 

Physical examination in these cases reveals in the vast majority 
of instances a characteristic condition of the surface of the abdomen. 
On the introduction of food there is a peristalsis visible to a greater 
or less extent on the surface of the abdomen. This peristalsis begins 
underneath the left costal border, passes forward to Traube's triangle, 
and there seems to stop, being interrupted by a sort of groove, and is 
taken up again by a second wave of peristalsis which passes onward 
beyond the ensiform cartilage, then downward, and disappears (Fig. 
108). 

Fig. 108. 



Peristalsis as seen in congenital pyloric stenosis. Case of Ibrahim. 

Some authors have described a reverse peristalsis just previous to 
vomiting, but I could never convince myself of the fact, possibly 
because I have not seen these particular cases. If there is a reverse 
wave of peristalsis, it must be instantaneous, and I have not yet 
observed it. Ibrahim also expresses his lack of information on this 
reverse wave. In some cases I have seen the peristalsis so extreme 
that just previous to vomiting the stomach would in a manner erect 
itself on the abdomen and divide itself distinctly from what appears 
to be the pyloric end of the stomach ; it would contract, and then the 
vomiting would take place. 

The vomiting is projectile in its nature, as if there was a sudden 
violent contraction of the stomach and a forcing upward of the con- 
tents. In some cases careful examination during this period of con- 
traction and peristalsis reveals a small hard nodule, cartilage-like in 
consistency, situated sometimes beneath the liver or its border and 
running directly downward toward the umbilicus. This structure, 
situated deeply against the vertebral column, is undoubtedly the 
pyloric end or valve of the stomach as it meets the duodenum. 



DISEASES OF THE STOMACH AND INTESTINES. 



515 



Some authors like Ibrahim have described singultus in these 
cases, and also eructations of gas, but inasmuch as these are quite 
common in healthy breast-fed infants, it seems to obscure the picture 
by laying any stress upon them. 

The peristalsis which I have described is present in a majority 
of cases, but it is not necessarily an accompaniment of all of them. 
It is sometimes entirely absent during the height of the affection, and 
is only seen at times. The pylorus also may not be palpable, and may 
not be felt at times. . As to the peristalsis, we must be very careful 
also how we conclude as to its presence or absence. A normal mild 
form of peristalsis seen in emaciated infants must not be confounded 
with the violent peristalsis present in some forms of this affection. 
Some of the most violent cases of vomiting with spasm or congenital 
stenosis of the pylorus have passed through my hands without the 
detection of the situation of the pylorus. 

Diagnosis. — Clinically there should be a distinction between cases 
which seem to be those of pure spasm of the pylorus with only relative 
or temporary stenosis and those in which there is a true hypertrophy 
with stenosis of the pylorus of congenital origin. In simple spasm 
there is persistent vomiting, retention of stomach contents, steady 
emaciation, and constipation. There may be no peristalsis and the 
pylorus is not distinctly felt. If indeed it is palpable, it is only so 
as a very small, indistinct nodule. There are one or two daily stools 
which contain a very small amount of milk fasces. In hypertrophic 
stenosis all the above symptoms are present to an aggravated degree. 
There is marked visible peristalsis, the constipation is complete, the 
stools show no milk fasces, only bile-stained mucus. The pylorus is 
distinctly palpable. 

Congenital conditions, such as real growths of the pylorus or 
atresia of the pylorus, are exceedingly rare, and can scarcely be 
brought into consideration in connection with conditions which are 
considered in this paper. The symptoms in congenital atresia and 
growths which completely obstruct the pylorus must come on imme- 
diately after birth, and are rapidly fatal, unlike the conditions in 
which the symptoms appear some time after birth. Congenital 
stenosis of the jejunum or duodenum may be confounded with that 
of stenosis of the pylorus, if the congenital atresia of the gut is 
situated high and near the pylorus. There may then be a series of 
symptoms on the part of the stomach indistinguishable from those 
of pyloric obstruction. 

Pure pyloric spasm, I feel, may well occur and doi^s occur with 
very slight hypertrophy of the pylorus, giving rise to only a limited 
form of stenosis. Ibrahim doubts the existence o( pure pyloric spasm, 
but I have tried to shew (hat it does occur, and this also in quite a 



516 DISEASES OF TEE STOMACH AND INTESTINES. 

percentage of cases : more especially is this so in those cases of per- 
sistent vomiting in which there is sudden or gradual cessation of 
symptoms upon the inauguration of correct diet and feeding. I 
think, in considering the question as to whether a spasm or severe 
form of stenosis is present, one of the most useful clinical guides is 
the amount and quantity of the stools. 

If in a given case the stools consist mostly of bile-stained mucus 
and very little faecal matter, in spite of the ingestion of an ideal food, 
such as breast milk, we are driven to the conclusion of the presence 
not only of spasm of the pylorus, but also of narrowing and stenosis 
of high degree. If, in spite of vomiting at every feeding, peristalsis 
and even a palpably contracted gut in the region of the pylorus, 
there is one or two stools daily containing some milk faeces, we must 
feel, as in certain of my cases which at times appeared hopeless, that 
the stenosis at the pylorus is not of high degree, and that the spasm 
relaxes at times and allows a certain amount of food to pass and 
nourish the patient. It is in most of these cases that we can feel that 
the ultimate outcome will be favorable, no matter how exasperating 
present symptoms appear to be. 

Prognosis. — The ultimate fate of these cases is extremely inter- 
esting in view of the recent contention from some quarters that as 
soon as the diagnosis of hypertrophic congenital stenosis is made 
the surgeon must interfere in behalf of the infant. I have tried to 
show that a large number of cases are really spasm cases, and will 
eventually recover on internal therapy. Persistent trial of feeding, 
the most diverse, will eventually result in overcoming the condition. 

As to the ultimate prognosis of true hypertrophic stenosis of the 
pylorus my own feeling is that there can be no absolute statement to 
fit all cases. The majority, I am certain, will recover under per- 
sistent attempts at feeding, and from my own experience ultimate 
recovery by internal management is not impossible in cases which it 
would seem must be operated upon. It is the exceptional case which 
will come under the notice of the surgeon. According to some writers 
fully 85 per cent, of the cases of spasm or stenosis will recover with- 
out resort to the knife. My own experience, which is quite large, 
seems to support this contention. 

Treatment. — I shall consider for conciseness: (a) Feeding; (b) 
mechanical means of therapy; (c) drugs; and (d) operative means. 

Feeding. — In a given case of hypertrophic stenosis or of congen- 
ital spasm the feeding is undoubtedly by far the most important 
element in the treatment. Breast feeding is the ideal method of 
feeding these cases, but not every breast will be found adapted to 
the infant. The breast is given at long intervals and short nursings. 
Many infants who have not improved on a given breast, or to whom 



DISEASES OF TEE STOMACH AND INTESTINES. 



517 



a breast is not available, will be tided over their illness by some of the 
many and diverse forms of substitutes for the breast at command of 
the physician. 

I do not think any artificial food is ideal, and no one is a panacea 
in this condition. Some insist that the food contain a minimal fat, 
and I have seen many cases recover on a food which all pediatrists 
agree is the most unsuitable in the long run under ordinary con- 
ditions. In other words, though this condition seems in a certain 
proportion of cases to have been inaugurated by some error in diet, 
there is no royal road to the feeding. In artificial as in breast feed- 
ing the method must presuppose small amounts at each feeding, at 
long or short intervals, as the case may be. 

Mechanical. — Mechanical means of therapy include the applica- 
tion of warm cataplasms of flax seed and hops, or dry warmth, stomach 
washing, and enteroclysis. Stomach washing is in some cases, when 
the infant is in a weakened condition, an exhausting procedure, 
though some observers, such as Pfaundler and Peer, laud its use 
highly. It may be tried at first and if no immediate relief result it 
should be suspended. 

Gavage. — I have used gavage with some degree of success in cer- 
tain cases and recently Saunders has had markedly favorable results 
with this procedure. By it fixed amounts of food are introduced into 
the stomach at intervals. 

Enemata are useful in the form of enteroclysis of small amounts 
of normal saline solution to maintain nutrition. They are given 
several times daily. 

Drugs. — Heubner advises opiates, others derivatives of opium, in 
very small amounts to quiet the spasm of the pylorus and adjacent 
stomach wall. Heubner uses the tincture. In most of my cases no 
opiate was resorted to, and in only one was it given, and then only 
after improvement was well inaugurated and only in exceedingly 
small doses and at desultory intervals. I have found but temporary 
benefit from the administration of citrate of soda, or soda and 
pancreatin. 

Operative Therapy. — An operation such as is proposed for the 
relief of congenital hypertrophic stenosis of the pylorus presupposes 
great technical skill on the part of the surgeon. The published mor- 
tality under the knife varies from 50 per cent, to 75 per cent, ami 
this does not give us any idea of the cases which have in the hands of 
some surgeons given a higher mortality. The operation of selection 
is posterior gastroenterostomy. 

Acute Gastro-enteric Infection (including Cholera Infantum) 
(Summer Diarrhoea; Acute Gastro-enteric Infection). — Acute gastro- 
enteric infection is a form oi' intestinal disturbance usually accom- 



518 DISEASES OF THE STOMACH AND INTESTINES. 

panied by gastric svniptoms. It is prevalent in the summer, but 
may also occur during the winter months. Bottle-fed infants are 
more subject to the affection, although it occasionally attacks infants 
at the breast. In institutions epidemics of the disease occur in 
breast-fed infants. In large cities more than one-half the deaths 
among infants under the age of twelve months are caused by summer 
diarrhoea. In Paris. ChaterinkofT found that of 20,000 children 
dying of gastro-intestinal disorders, fully three-fifths were bottle-fed. 
This high rate of the mortality of bottle-fed infants, as compared with 
that of breast-fed infants, is not alone due to the difference in the 
nature of the food; no matter how carefully it is handled before it 
reaches the infant, milk passes through many channels, and in each 
of these it is exposed to infection. The intense heat of summer also 
favors the increase of infectious agents. 

Etiology and Classification. — The various forms of acute gastro- 
intestinal infection may be divided into those whose source of infec- 
tion lies outside the body (ectogenous) and those in which the elements 
of infection are pre-existent in the body (endogenous). This classi- 
fication (Escherich) is both practical and in accordance with the 
results of recent study. 

In the first class are included the diarrhoeas of toxic origin and 
cholera infantum; in the second are included the diarrhoeas which 
are caused by varieties of bacteria pre-existent in the intestine, but 
which, in the opinion of Booker, Escherich, and Marfan, may under 
favorable conditions increase to enormous numbers and become viru- 
lent. According to Booker, no one specific micro-organism is the 
essential cause of acute summer diarrhoea. Escherich has shown 
that the coli group may under certain conditions become virulent. 
Of the bacteria which are found in certain forms of gastro-intestinal 
infection, the Streptococcus enter it idis seems to have attracted the 
greatest atttention. Booker first insisted on the importance and pecu- 
liar role of this micro-organism. He found these streptococci in 
great numbers not only in the stools of infants suffering from acute 
summer diarrhoea, but also in the walls of the gut and in the various 
organs of the body. Escherich and his pupils, Libman and Hirsch, 
have confirmed the results of Booker. Escherich regards the Strep- 
tococcus enteriditis as an ectogenous infection. The udder of the 
cow may be the source of this micro-organism. Marfan and Booker 
are also inclined to believe that streptococci are able under certain 
conditions to increase in number and virulence and that they are one 
of the endogenous forms of infection by a micro-organism normally 
present in the out. Among the other bacteria found in enormous 
numbers in the movements of infants and children suffering from 
acute gastro-enteric infection are the Bacillus pyocyaneus (Kosseland 



DISEASES OF THE STOMACH AND INTESTINES. 519 

Baginsky), Proteus vulgarus (found by Booker in choleriform diar- 
rhoea), and the proteolytic bacteria. 

The second class comprises peptonizing bacteria, such as the Ba- 
cillus subtilus, Bacillus mesentericus vulgatus, and Tyrotrix tenuis. 
These peptonizing bacteria are not found in the gut or stools of the 
breast-fed infant either when in good health or sick. We may thus 
classify all diarrhoeas of acute gastro-enteric infection as follows : 

1. Those due to improper food, or the so-called mechanical irri- 
tative diarrhoeas (Booker). 

2. The infectious forms (endogenous and ectogenous). This 
class would include the toxic diarrhoeas of some authors. 

~Not only the food and the bacteria, but also certain changes in 
the intestine play an important role in acute gastro-enteric infection. 

Morbid Anatomy. — Stomach and Intestines. — Booker has described 
a superficial loss of the epithelium of the stomach and gut, as a con- 
stant lesion in all fatal cases of gastro-enteric infection. It may be 
intact in some places and destroyed or eroded in others. The mucous 
membrane of the jejunum and duodenum may show less denudation 
than other parts of the gut. The epithelial layer of the mucosa is infil- 
trated with leucocytes in diffuse areas or nests. The infiltration may 
push the epithelial layer upward. The mucosa itself is infiltrated 
with polynuclear and mononuclear leucocytes to a varying extent. 
The mucosa shows superficial or deep ulcerations involving the crypts 
or villi. Heubner has described a form of necrosis which chiefly 
affects the epithelial structure without involving the deep mucosa. 
This occurs in cholera infantum. Booker also describes a bronchitis 
and a form of bronchopneumonia which are quite constantly found 
in fatal cases. Hemorrhages into the lung tissue are common. 

Kidneys.- — In the kidneys there is necrosis of epithelium in the 
convoluted and irregular tubules (Booker). 

Liver. — The liver shows fatty degeneration and necrosis of the 
liver-cells. 

Lymph-nodes. — The lymph-nodes show focal necrosis. 

The Role of the Bacteria. — Booker has demonstrated that no bac- 
teria are found in the mucosa of the intestine if the superficial epi- 
thelium is intact. If there is a lesion of continuity of the superficial 
layer, the bacteria invade the mucosa in large numbers. There is 
reason to believe that the toxins generated by the bacteria in the gut 
cause the superficial erosions and prepare the way for invasion of 
the lymph-channels and bloodvessels. Bacteria arc not always found 
in the lesions, but as a rule the ulcerations o( the mucosa show vast 
numbers. Booker found bacteria in cultures taken from the solid 
organs and blood, (hns confirming what C/.ornv and Mozer found to 



520 DISEASES OF THE STOMACH AND INTESTINES. 

be the case during life. The lungs especially showed large numbers 
of bacilli and cocci. 

Symptoms. — In the mild form of gastro-enteric infection the infant 
is restless and cries at intervals because of colicky pains. It may 
previously have been in good health, but with the advance of these 
symptoms there will also be noticed a slight febrile movement and a 
disinclination to take the bottle or breast. Vomiting occurs after 
feeding, the rejected contents of the stomach being curdled and having 
a marked acid odor. In mild cases the vomiting is usually not severe. 
It may be repeated three or four times in the twenty-four hours. The 
movements are at first normal; they afterward become frequent and 
contain whitish curds or greenish and white curds, are more fluid than 
is normal, and may have a very offensive odor. In mild cases there 
may be only two or three such movements in the twenty-four hours 
or they may number six or more. Later, the fever also becomes more 
marked, the temperature sometimes mounting as high as 103° F. 
(39.4° C). If the feeding is continued, the vomiting persists. The 
infant shows little or no prostration. 

In severe cases the vomiting is marked from the outset. The 
infant not only vomits its regular food, but will also often vomit all 
fluid that is taken into the stomach. The diarrhoea is also more 
severe than in the mild forms. The movements are at first yellow 
or greenish and contain white curds, but as the disease advances they 
become more fluid, until in very severe cases only a greenish malo- 
dorous liquid containing small particles of mucus and faecal matter 
is voided. The infant has a febrile movement which varies from 
101° to 103° F. (38.8° to 39.4° C), and there is marked prostra- 
tion. In the acute forms of gastro-enteric infection there is consid- 
erable loss of weight; the infant becomes pale and languid, and the 
pulse is rapid and weak ; the number of daily evacuations may reach 
twenty. In some cases the straining causes a descent of the lower 
part of the rectum, and the movements contain a slight amount of 
bloody mucus. The odor of the evacuation may not be offensive. 

If the patient improves, the symptoms retrograde — the vomiting 
becomes less frequent, the stools more faecal in character and less 
numerous, and the fever subsides. If, on the other hand, the symp- 
toms progress, the movements not only continue frequent and fluid, 
but also blood and particles of mucus are mingled with the faecal mat- 
ter. The vomiting may cease entirely. The infant loses in weight 
steadily; the movements are small and passed with tenesmus; the 
patient passes into the subacute stage. In some cases there is colic ; 
the infants are restless or pass into an apathetic condition. Little 
urine is passed, and in the majority of cases of mild or severe gastro- 
enteric infection albumin is present. It rarely amounts to more than 



DISEASES OF THE STOMACH AND INTESTINES. 521 

a trace. In severe cases there are leucocytes and epithelial, hyaline, 
and blood-casts in the urine ; sometimes in addition a few blood-cells 
are found. 

In the subacute forms of gastro-enteric infection which last for 
more than a week, bronchopneumonia may be a complication. This 
form of bronchopneumonia is described in the section on Pneumonia. 
In some cases it is of short duration, in others persistent. Broncho- 
pneumonia with slowly resolving areas of consolidation in the lung 
is the type met with. 

Course and Prognosis. — The prognosis of the mild forms is good, 
if proper measures are adopted. The severe forms are exceedingly 
fatal in summer. The mortality varies with the environment. In 
the crowded tenements of large cities and in unhygienic surroundings 
the mortality is great, as is also the case in institutions and hospitals. 
In private practice the isolation of the patient and special nursing 
reduce the mortality to a minimum by preventing reinfection. Rein- 
fection is caused by lack of care in handling the diapers and in pre- 
paring the food, by giving improper food, and by placing a number 
of cases in the same room. There can be no question that in hospitals 
patients are affected unfavorably by proximity to other patients suf- 
fering with the same disease. No matter how careful the nursing 
under such circumstances, reinfection cannot be prevented. Also, 
perfect cleanliness is not attainable in hospitals as in private practice. 

Treatment. — See under Cholera Infantum. 

Cholera Infantum. — Cholera infantum is the severest form of 
summer diarrhoea prevalent among infants. It is believed that it 
has a specific origin, but this has not as yet been demonstrated. 
Cholera infantum does not occur so frequently as has been hitherto 
supposed. Of hundreds of cases of gastro-enteric infection of the 
acute variety which come under my care yearly, only a few can be 
called typical of this form of infectious diarrhoea. These cases occur 
for the most part in weakly bottle-fed infants. Breast-fed infants 
may occasionally be affected, especially in hospitals. 

Symptoms. — The infants as a rule have been suffering from a 
mild diarrhoea. Following a slight febrile movement, vomiting and 
diarrhoea of a severe and exhausting character set in. The bowel 
movements are frequent, but contain very little faecal matter after the 
first few have been passed. They are at first greenish, afterward 
becoming watery, resembling barley-water; they contain but a few 
flocculi of mucus, and may not have much odor. The vomiting is 
incessant. First the stomach contents are vomited, and finally a 
greenish fluid. Within a few hours the infant is reduced to a condi- 
tion of great prostration. The loss of weight is marked, oven in the 
first twenty-four hours. The skin on the thighs is wrinkled. 



522 DISEASES OF THE STOMACH AND INTESTINES. 

The face and trunk are pale and the face is drawn. There is 
fever to a marked degree (101°-103° F., 38.3°-39.4° 0.), and the 
pulse is rapid and thready. Toward the close the movements are 
passed involuntarily. The whole picture is that of a choleriform 
disease. As the fatal issue approaches the eyes become sunken and 
glassy, the fontanelle is depressed, and the mouth is open. The con- 
dition described elsewhere as hydrocephaloid sets in. Convulsions 
and a rise of temperature (105° to 107° F. ? 40.5° to 41.6° C.) pre- 
cede the fatal issue. 

Occurrence. — These severe choleriform diarrhoeas resemble Asiatic 
cholera very closely, and should be sharply differentiated from severe 
forms of gastro-enteric infection. They occur in bottle-fed infants 
under the age of two years, and chiefly in the months of July and 
August. Heat and infected food are the main etiological factors. A 
diarrhoea of a mild type is the forerunner in the majority of cases. 
These cases are not so frequent to-day as they were in the days when 
infants were fed with decomposed milk containing bacterial toxins. 
This form of diarrhoea must therefore be looked upon as a purely 
ectogenous infection. 

Duration and Prognosis. — The prognosis in the majority of cases 
of cholera infantum is grave. The disease is an exceedingly fatal 
one, occurring as it does for the most part in infants fed on the bottle 
whose general condition is poor. It lasts for from twenty-four 
hours to two or three days. The rapidity of the development of the 
symptoms and of the fatal results precludes the possibility of any 
complications other than those due to the great drain on the system. 
The condition of hydrocephaloid is hardly a complication ; it is a ter- 
minal set of cerebral symptoms. Sclerema, mentioned by some 
authors, I have not met in true cholera infantum; it is seen in the 
terminal stage of acute forms of gastro-enteric infection. This form 
of sclerema affects the thighs at the upper and inner part. It is 
described in the section devoted to that subject. 

Kjelberg, Felsenthal, Bernard, Morse, and the writer, found 
albumin and casts in the urine of children suffering from all forms of 
gastro-enteric infection, acute and subacute, including cholera in- 
fantum. 

Morse as well as the author found that the urine was concentrated 
and contained hyaline, granular, and epithelial casts, with leucocytes 
and blood and blood-casts. The albumin is rarely present to a marked 
degree. It is a trace or a distinct reaction. The urine is suppressed 
in severe cases, and lessened in quantity in others. In some cases 
of the severe types there is slight oedema of the subcutaneous tissues, 
especially on the inner part of the thighs, the legs, and dorsum of the 
foot. We are not in a position to trace any close relationship between 



DISEASES OF TEE STOMACH AND INTESTINES. 523 

the general symptoms and the disturbances of the kidney. The 
toxaemia in this disease, causing as it does vomiting and nervous symp- 
toms^ masks the nephritic symptoms if they are present. 

Diagnosis. — The diagnosis of acute gastro-enteric infection is not 
difficult. There are, however, many infectious diseases, the onset of 
which it closely resembles. Scarlet fever, for example, begins with 
vomiting, and in some cases with diarrhoea. There is a form of 
grippe which in its onset, with vomiting and diarrhoea, closely resem- 
bles an attack of gastro-enteric disease. In fact, these symptoms may 
persist in the course of the former affection. 

The physician should not be satisfied with a history of gastro- 
enteric symptoms, but should carefully examine the skin, throat, and 
chest at every visit. In the severe forms of diarrhoea a small particle 
of the movement may be spread on a cover-glass and examined for 
an excessive number of streptococci. In mild, protracted forms of 
diarrhoea we should not fail to make a Widal test of the blood and a 
count of the leucocytes, to eliminate the possibility of typhoid fever. 
This will especially be indicated in cases in which there is enlarge- 
ment of the spleen. 

Treatment of Acute Gastro-enteric Infection and Cholera Infantum. — 
Prophylaxis. — The nursing bottles when emptied by the infant should 
be filled with a saturated solution of sodium bicarbonate, allowed to 
stand for a few hours, and then carefully washed inside and out with 
a bristle brush. The nipples should be sterilized daily. The nurse or 
mother, after attending to the diapers of the infant, should carefully 
cleanse the hands before feeding the baby. The milk should be diluted 
as directed in the section on Infant Feeding, pasteurized or sterilized, 
and then kept on ice until needed. The milk should be fresh and 
delivered for modification within a few hours of the milking-time. 
The nursing should be conducted at stated intervals. If there is a 
residue in the nursing bottle, it should not be utilized for a subse- 
quent nursing. The infant is given a full bath daily. By attend- 
ing to all these details, infection of the food and of the infant may 
be avoided. With breast-fed infants prophylaxis is of great impor- 
tance. A baby at the breast should be fed at regular intervals. The 
breast-nipples should be washed with a saturated solution of boric 
acid before and after nursing. The baby should not be allowed to 
nurse a breast with a fissured nipple. The milk of such a breast is 
pumped off, and an attempt is made to heal the nipple in the manner 
elsewhere described. If there is caking f the breast, the condition 
should be remedied before the infant is allowed to nurse. Abun- 
dance of fresh air and bathing are indicated in these infants as in 
bottle-fed infants. 

Sick Infants. As soon as a baby shows signs o( even mild dys- 



524 DISEASES OF TEE STOMACH AND INTESTINES. 

pepsia or gastroenteric infection the milk should be discontinued, a 
simple cathartic given, and the infant kept for twenty-four hours on a 
solution of egg-albumin. Vomiting which has occurred only once or 
twice does not call for active treatment, as it will disappear as soon 
as the milk is discontinued. After the bowels have moved, if the 
infant shows no exacerbation of symptoms feeding should be resumed 
cautiously. In this way a severe illness can be averted. If the food 
is not suitable, causing signs of dyspepsia such as colic, it should be 
changed if possible, else severer symptoms may result. If in spite 
of all precautions an attack develops, the patient should be treated 
on the following lines : 

1. The food is stopped and another of a safe character substituted. 

2. The toxins are eliminated and the strength of the patient sup- 
ported by the so-called mechanical methods. 

3. Drugs are used to abate the symptoms and support the strength 
of the patient. 

The milk, whether of the breast or bottle, is discontinued. The 
infant is given a solution of albumin-water, acorn-cocoa, or beef-juice 
expressed and diluted with barley-water. A baby can be kept for 
days upon these mixtures without any danger of reducing the strength. 

According to Czerny. 100 c.c. of breast milk are equivalent to 
61 calories; 100 c.c. of the white of egg are equal to 75.1 calories. 
The white of one egg weighs about 30 grammes ; therefore the white 
of an egg is equal to about 25 calories. It is digestible, and is well 
borne by infants. Albumin-water may be used alternately with the 
solution of acorn-cocoa or beef -juice and barley-water. To older 
children we may sometimes have difficulty in administering albumin- 
water or acorn-cocoa. Under such conditions, when the acute stage 
is passed. I frequently resort to a dextrinized gruel or the so-called 
Liebig's soup mixture which Keller devised. 

The cathartic given at the onset should be castor oil or calomel, -J 
grain (0.03) doses twice or three times a day. Infants who are vom- 
iting are given calomel in preference to castor oil. 

Vomiting. — If the vomiting is not severe and the case is under 
treatment from the onset, it is best not to wash out the stomach at 
once. It often happens that the vomiting ceases as soon as the regular 
food is stopped. If, however, the vomiting persists for twenty-four 
hours, we proceed to wash out the stomach. If the vomiting con- 
tinues after this, it is either toxic or may in rare cases be due to 
some other causes. As a rule, it ceases after one irrigation of the 
stomach. 

Diarrhoea. — The diarrhoea is controlled by irrigation of the gut. 
The rectum and gut are washed out in those cases in which the diar- 
rhoea is not only persistent, but progressive. The object in washing 



DISEASES OF THE STOMACH AND INTESTINES. 525 

out the lower bowel is two-fold: (a) to remove any residue of faeces 
that may have collected in the lower bowel and rectum, and to stimu- 
late peristalsis and thereby favor evacuation from above; (b) to 
stimulate the heart and add to the body an amount of normal solu- 
tion to compensate for the drain caused by the diarrhoea. The Can- 
tani normal salt solution is utilized in the manner described. 

The rectal enemata are given under a pressure obtained by an 
elevation of at most two feet from the bed. A temperature of 107° 
to 110° F. (40.5° to 43.3° C.) is the best and most stimulating in 
these cases. Fully a quart of water is thrown into the rectum in 
half-pint portions. As the half-pint flows in, the funnel on the rectal 
tube is disconnected and the contents of the bowel are allowed to 
escape. Another portion is then allowed to flow into the bowel. The 
water will sometimes escape alongside of the tube. This is rather a 
favorable sign, being significant of the contractile powers of the gut 
and abdominal walls. Only two enemata daily are necessary, even 
in severe cases. As the diarrhoea and symptoms subside we reduce 
the number of enemata to one, finally discontinuing them entirely 
as the infant improves. 

It sometimes happens that after a few days the enemata are fol- 
lowed by movements containing blood and mucus, the tenesmus being 
aggravated. In these exceptional cases an enema must be given only 
every other day, and the effect on the rectal discharges watched. By 
stopping the enemata altogether it can be determined whether the dis- 
charges of mucus and blood are caused by the therapy or the disease. 

Hypodermoclysis. — The injection of normal salt solution under 
the skin is indicated only in the severe cases in which, as in cholera 
infantum, the course of the disease is rapid and the prostration ex- 
treme. Personal experience rather discourages the employment of 
large injections by this method. I have seen two cases of infection 
by the Bacillus capsulatus aerogenes (Welch) following hypoder- 
moclysis. These occurred through the use of saline solution evidently 
insufficiently sterilized, and which had probably been allowed to stand 
before being used. In a third case hemorrhages over large areas 
occurred at the point of the injection of the salt solution. These 
injections are also very painful. 

Because of these dangers and disadvantages the subeutaneous 
injections of salt solutions should be utilized as a last resource in 
desperate cases. Small rather than large amounts of fluid should be 
injected subcutaneouslv. The sail solution for the hypodermocljsis 
is that of Cantani. It should be sterilized at a temperature of 212° 
F. (100° C.) for at least an hour, to kill sporulated bacteria if 
possible. 

Baths. — In all cases, whether with or without elevation o( tem- 



526 DISEASES OF THE STOMACH AND INTESTINES. 

perature, the benefit obtained from warm baths cannot be overesti- 
mated. In cases of great prostration a bath at 108° F. (42.2° C.) 
for five minutes is stimulating to the nervous centres and is followed 
in many cases by diminution of the apathy and an apparent reduction 
of the effects of toxaemia. If the temperature rises above 103° F. 
(39.4° C), sponging with water at 80°-85° F. (26.6°-29.4° C.) 
is all that is needed. This should not be done oftener than once in 
every three hours. 

Alcohol. — Of late years, alcohol is given less and less in cases of 
acute gastro-enteric infection. In these cases there is a special intol- 
erance, of the stomach and also of the economy to alcohol. Infants 
after taking it for twenty-four hours will become stupid, apathetic, and 
exhibit a constant retching if they do not vomit. This appears to be 
due more to the effect of the alcohol locally on the stomach and also 
systemically than to toxaemia of the disease. I therefore deprecate 
the use of alcohol except in extreme cases, when whiskey is given in 
small doses at short intervals. 

Strychnine. — Strychnine is useful; grain %oo (0.0002) is given 
to an infant of six months, and grain /4oo (0.0003) to older infants 
every three hours. 

Atropine. — Atropine, lately advised as a cardiac stimulant in 
these cases, especially in cholera infantum, is of questionable utility, 
and should not be employed. I have seen grain %50 (0.0004) give 
rise to constant tremulous and convulsive twitching. 

Resorcin. — If the vomiting is constant, grain -J (0.008) of resor- 
cin given every three hours is a safe and very useful remedy. 

Bismuth. — Bismuth in the form of the subcarbonate is the only 
drug useful in allaying the vomiting and the tenesmus of the bowel. 
Grains ij or iij (0.12 or 0.18) are given in powder form every two 
or three hours. 

Opium. — Opium in any form has fallen into disuse. In the 
severe cases it is dangerous, and may increase the prostration ; in the 
milder cases its use is justifiable only if the colicky pains are exces- 
sive. The milder preparations such as the wine and the camphorated 
tincture are of value, because they can be given in graduated doses, 
and the effects determined more exactly than can be done with the 
stronger preparations. 

Salol. — Salol in grain \ (0.03) doses every three hours may be 
combined with the bismuth to allay the colicky pains. 

Tannigen. — Tannigen is a useful drug in the chronic forms of 
intestinal disease, but an irritant in the acute forms. 

Colic. — Colic has been mentioned so often that a few words as to 
the treatment may not be out of place. Passing of the rectal tube 
rarely relieves it. A small rectal enema has been found to be a very 
effective remedy. 



DISEASES OF THE STOMACH AND INTESTINES. 527 

As the symptoms improve care should be taken not to return to 
a milk diet too quickly. The milk is given in dilutions and is steri- 
lized carefully. Infants in an enfeebled condition as a rule bear this 
form of milk best, since it is not apt to be irritating to the gut. When 
the danger is past any form of milk may be given — raw, pasteurized, 
or sterilized — care being taken that all the precautions as to freshness, 
cleanliness, and proper preparation are observed. I have mentioned 
the fact that before returning to dilutions of milk the exhibition of 
dextrinized gruels has been successful with very weak infants. The 
malt, the cereal, and the milk acted upon by the ferment contained in 
these mixtures are all easily digestible and assimilable, and promote 
increase of weight. As a matter of course, the effect of the gruel 
mixture on the stomach and gut should be carefully studied. 

Whatever methods are employed in the treatment, it is necessary 
to avoid the error of overtreatment. It should be remembered that 
hours of rest do more than hours of treatment. Three-hour intervals 
should elapse between the application of remedial measures. Fresh 
air in the room or a sojourn of a few hours in the open with absolute 
quiet, is of the greatest value in these cases. 

Acute and Subacute Enterocolitis {Enteritis Follicularis; En- 
teric Catarrh). — Enterocolitis is peculiarly a diarrhoeal disease of 
infancy and early childhood. It was formerly classified as a form 
of dysentery, because in these cases the movements are tinged with 
blood and contain mucus. The cases are, however, of a milder type, 
and present many symptoms foreign to true dysentery. 

Etiology. — In many of its features this affection resembles acute 
and subacute gastro-enteric infection. It is prevalent during the 
summer months. It occurs in infants after the first year of life, and 
may be primary or follow an ordinary dyspeptic diarrhoea, one of the 
exanthemata, pertussis, or bronchopneumonia. Booker his described 
the great number of streptococci found in certain of these cases. Fink- 
elstein and Escherich and his pupils have confirmed these results, and 
have in addition presented the view that these diarrhoeas are infec- 
tious and may be caused by bacteria of the coli group. The bacteria 
may be introduced from without, or the coli organism in the gut under 
certain conditions may become virulent. With reference to their 
origin, these cases may be considered as bearing a relationship to 
cases of true dysentery, from which with our present imperfect knowl- 
edge it is not always possible to distinguish them. 

Morbid Anatomy. — The mucous membrane is hypersemic and 
swollen; in cases of long duration the mucosa is infiltrated with small 
round cells. The follicles of the gut are enlarged and elevated above 
the surface of the mucous membrane. The Peyer's patches are en- 
larged and surrounded by a zone of hvperaania. The villi shew 



528 DISEASES OF THE STOMACH AND INTESTINES. 

desquamated epithelium and infiltration of the walls with small round 
cells. The follicles are swollen, and at the surface may burst and 
present follicular ulcers. The epithelium of the gut may be lacking 
in places. 

Symptoms. — In the beginning there are fever and slight vomiting. 
The movements are fluid, greenish, and have a disagreeable odor, 
contain mucus, and are streaked with blood. They may number ten 
or twelve in twenty-four hours. Straining at times accompanies the 
movement. As a rule the infant is pale and prostrated. The char- 
acter of the movements is unchanged for days or weeks, when improve- 
ment begins and recovery ensues. On the other hand, in protracted 
cases the infant may develop a bronchopneumonia in one or both 
lungs, but may even then recover under good management. The pic- 
ture thus resembles that of a mild dysentery, but the subjects are 
younger, and there is in a number of cases a history of antecedent 
intestinal disturbance of extensive duration. 

Treatment. — The treatment should be carried out on the same lines 
as in acute gastro-enteric infection. Caution should be exercised in 
returning to a diet composed exclusively of milk. While in true dysen- 
tery in older children I advise the administration of milk sterilized 
in some form, in younger infants such a procedure would be unwise. 
I keep these infants on a diet devoid of milk, such as beef-juice and 
barley-water, albumin-water or solution of acorn-cocoa, as long as 
possible. As the character of the movements improves the infants 
are put on a dilution of albumin-water and milk or cocoa and milk, 
or, what is far preferable, dextrinized gruel and milk. The amount 
of milk in the dextrinized mixture is gradually increased until the 
quantities appropriate to the age of the infant are given. 

Dysentery and Paradysentery (Ileocolitis ; Colitis Contagiosa; 
Coli Colitis; Enteritis Follicularis; Enterocolitis) . — Dysentery is an 
acute infectious diarrhoeal affection of the intestine. In the United 
States it occurs both sporadically and in localized epidemics. It is 
endemic in the tropics, where the etiology is somewhat different from 
that in our climate. The amoebic infection seems, according to Kar- 
tullis, to be characteristic of the tropical form. Although amoebic 
dysentery is occasionally seen here sporadically and in cases of per- 
sons recently returned from the tropics, it is not the form which com- 
monly occurs in infants and children. The form to which these 
patients are liable is seen during July, August, and September, and 
late in the autumn. It may affect nurslings who are fed artificially, 
but most often occurs in children who are on a mixed diet. Escherich 
has described epidemics of limited character in private families and 
hospitals. I have met this form of dysentery in sporadic cases or 
small local outbreaks, and have also seen outbreaks at seaside resorts 



DISEASES OF THE STOMACH AND INTESTINES. 529 

among children of from two to four years of age who had partaken 
of drinking-water which had been rendered unfit for use by con- 
tamination. 

Forms. — There are three forms of the disease: (1) the true epi- 
demic dysentery which occurs occasionally in America and on the 
Continent but is epidemic and endemic in the tropics; (2) the 
amoebic form, which is also endemic in the tropics; and (3) the form 
which occurs in infants and children in the summer months as a rule 
sporadically, rarely epidemically, except in institutions. 

Etiology. — The essential cause of dysentery or ileocolitis is now 
recognized to be bacterial. 

Shiga, in 1897 and 1898, isolated a bacillus from the fasces of a 
number of cases of dysentery occurring in Japan. He discovered 
also that the blood-serum of the persons afflicted caused a clumping 
of the bacillus isolated when mixed with cultures of the latter in the 
proper dilutions. These cases of dysentery cited by Shiga did not 
include the amoebic variety. The characteristics of the bacillus iso- 
lated from these cases closely resembled those of the bacillus of 
typhoid fever, except that it was not motile. 

In 1902 Flexner and his pupils, Duval and Bassett, studied 53 
cases of diarrhoea of the dysenteric type, and obtained cultures of the 
bacillus of Shiga in 42 of the cases investigated. Since then a num- 
ber of investigators have studied the dysenteries of children in local 
epidemics, and have substantiated the work of Duval and Bassett. 

In 1903, Flexner and Holt in a collective study of the occurrence 
of the true Shiga-Kruse bacillus and the Flexner bacillus in dysen- 
tery or ileocolitis of children found that the cases divided themselves 
into those in which the bacillus of Shiga-Kruse was found and those 
in which the Flexner bacillus was present. The cases of the latter 
class were the most frequent. It may be said that the form of ileo- 
colitis met with in the summer in infants and children is of the group 
caused by the Bacillus dysenterise of Flexner and allied bacilli, 
whereas the cases caused by the true dysentery bacillus of Shiga and 
Kruse are very uncommon. The Flexner bacillus differs from that 
of Shiga-Kruse in that it forms acid in media and does not ferment 
milk or sugar. Like the Shiga-Kruse bacillus it is immobile and 
unlike it has little tendency to form toxins. 

These facts have been confirmed by Jehle, Leiner and Kneepfel- 
niacher. It has therefore been proposed to reserve the term dysen- 
tery for the true epidemic tropical form of the disease and that of 
paradysentery for the endemic form of dysentery which occurs in 
infants and children and which is due to the bacillus dysenteria of 
Flexner and allied micro-organisms. The bacillus dysenteria Flex- 
ner has been found in the stools of normal children who have been in 

84 



530 DISEASES OF THE STOMACH AND INTESTINES. 

the vicinity of children suffering from dysentery or who in the past 
may have had an attack of the disease. Wollstein, however, failed to 
find it in a number of normal children. The coli bacilli (Escherich) 
and streptococci fonnd in the intestine in dysentery or paradysentery 
play an important role in the mixed infections of these diseases. 

Morbid Anatomy. — Dysentery may affect different sections of the 
intestine at the same time, the rectal or sigmoid flexure alone, the 
ascending colon, the transverse or the descending colon only. In rare 
cases the disease may pass beyond the ileocecal valve and involve the 
lower part of the ileum. There are two forms which may be present 
separately or simultaneously, the catarrhal and the necrotic form. 

In the milder catarrhal form of dysentery the mucous membrane 
is hypersemic and swollen, and the summits of the intestinal folds are 
studded with hemorrhages in small foci or streaks. The submucosa 
is infiltrated with small round cells and the vessels filled with blood. 
The epithelium of the follicles is swollen and proliferated, and there 
is infiltration of the surrounding connective tissue with round cells. 
In severe forms the surface of the mucous membrane is covered with 
mucus containing leucocytes and blood-cells. The follicles are ele- 
vated above the surface. In other cases the intestine is studded with 
ulcerations which mark the necrotic follicles. The ulcerations reach 
to the muscularis mucosa?. If the process extends to the small intes- 
tine the Peyer's patches are swollen and surrounded by a hyperaemic 
zone. 

If the disease has advanced to the necrotic stage, the mucosa is 
thickened and infiltrated with round cells. There are areas of loss 
of tissue which extend deep to the muscular coat (gangrene). The 
mucous membrane is covered with a grayish exudate of a pseudo- 
membranous character. In severe cases large areas of the mucous 
membrane may necrose and be cast off. The necrotic areas show 
an abundant invasion of bacteria of the streptococcus and coli type, 
in scattered masses or zooglcea. The lymph-nodes of the mesentery 
are swollen ; the spleen may be enlarged ; the kidneys may show degen- 
erative changes, and the lungs may be the seat of bronchopneumonia. 

Symptoms. — The symptoms of dysentery in infants and children 
closely resemble those seen in the adult subject. The onset may 
follow some indiscretion of diet or be entirely independent of any 
such error. There may be a preceding headache, and there is, as a 
rule, some fever. Abdominal pain is the first symptom until diarrhoea 
sets in. The diarrhoea at first resembles an ordinary dyspeptic diar- 
rhoea, but in a few hours or after one or two movements, it assumes 
the characteristics which mark it as specific. The patient passes 
stools which are fluid and contain mucus mixed with blood and shreds 
of tissue, and which may have an offensive odor. They are passed 



DISEASES OF TEE STOMACH AND INTESTINES. 



531 



with much abdominal pain and rectal tenesmus. If the abdominal 
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Necrotic colitis; fatal, in a girl six years of age. 

sists beyond a few days, there is rapid emaciation and the abdomen 
becomes sunken and board-like. In some cases palpation in the region 



532 DISEASES OF THE STOMACH AND INTESTINES. 

of the caecum and ascending colon may detect the contracted, thick- 
ened gut. In severe forms of the necrotic type it is possible to mark 
out the caecum and ascending colon as a contracted, thickened tube. 
In protracted cases the spleen becomes enlarged and the tongue dry 
and coated, in this respect resembling the condition seen in typhoid 
fever. Multiple hemorrhages may appear under the skin. The urine 
contains albumin, and in some cases hyaline and epithelial casts. 

Course. — The fulminating cases run their course in a few days 
with high fever, terminating in death. Other cases may be compara- 
tively mild and last only a few days or a week. In such cases there 
may be recurrences. In other cases the disease runs a course of from 
three to six weeks. After this period, from time to time, blood, evi- 
dently derived from bleeding ulcers in process of repair, may appear 
in the movements. The movements gradually become formed and 
faecal in character, and the patient recovers. In cases which have 
come under my care in hospital service, the disease ran a moderately 
severe course until the seventh or eighth day. The fever, however, 
remained high and delirium set in on the ninth day. The appear- 
ance of the patient became septic, sopor supervened, and the urine 
and faeces were passed involuntarily. Death took place on the thir- 
teenth day. In other cases of a severe necrotic type death took place 
at the end of a week. 

Complications. — The most dangerous complication is perforation 
and general peritonitis. Periproctitic abscess may occur, with sub- 
sequent fistula. In septic cases, abscess of the liver and spleen have 
been observed. Hemorrhages may occur under the skin late in the 
disease. In all of my cases these were quite extensive, but recovery 
nevertheless took place. In one fatal case I noted metastatic paro- 
titis. Some authors have recorded arthritis as a complication; as a 
rule it retrogrades and recovery takes place. 

Prognosis.- — The prognosis varies with the severity of the case. 
The mortality ranges from 30 to 40 per cent. The croupous or 
necrotic cases are very fatal. With good management the mild cases 
give a favorable prognosis. The severity of the infection and the 
prevalence of an epidemic will influence the course of the affection. 

Treatment. — Prophylaxis. — The movements are not only infec- 
tious, but may also communicate the disease to others if a particle 
is introduced into the gut. The hands of the patient and his body 
should be kept scrupulously clean to avoid reinfection. The move- 
ments should be disinfected in the same manner as those of a patient 
suffering with typhoid fever. The hands of the nurse should be 
scrupulously cleansed and washed in an antiseptic solution. 

General. — The patient is given a cathartic, preferably castor oil, 
as the initial step of treatment. In this way all irritating food par- 



DISEASES OF THE STOMACH AND INTESTINES. 066 

tides and residual fasces are cleared from the gut. All food, even 
milk, is withheld at first. The patient for the first twenty-four hours 
is given a solution of egg-albumin, acorn-cocoa, beef- juice broths, or 
expressed beef-juice and barley-water in equal parts. The following 
are the lines along which the later management of these cases should 
proceed : 

a. An absolutely non-irritating and easily assimilable food is given. 

b. The pain and tenderness are relieved with drugs, the diarrhoea 
being also partially controlled in this manner. 

c. The rectum is irrigated. 

After a day or two, during which the patient has been fed upon 
albumin- water, expressed beef-juice, and barley-water or acorn-cocoa 
solutions, sterilized or pasteurized milk is substituted. In these 
cases, as in typhoid fever, the patients are given during twenty-four 
hours, two or more quarts of milk sterilized at 212° F. (100° C.) 
or pasteurized at 164° F. (73° C). I wait until the severely acute 
symptoms have subsided before placing these patients on a milk diet. 
At best, milk leaves a large residue in the gut, and in the acute stage 
of the disease the coagulum may in a mechanical way irritate the 
acutely inflamed walls. Pasteurized and sterilized milk is well borne 
in the later stages of the affection. Milk in a raw state, no matter 
how good, will sometimes tend to aggravate the acute symptoms. 
Pain and tenesmus are relieved by the exhibition of Dover's powder, 
grains J to ij (0.03 to 0.12), every two hours according to the age 
of the infant or child. Codeine sulphate, grain i to i (0.01 to 0.015), 
according to the age of the patient, is preferable to morphine or tinc- 
ture of opium. The administration of powdered ipecacuanha will be 
found very useful in certain cases. In others the vomiting rather 
interferes with its administration; grains j to ij or iij (0.06 to 0.12 
or 0.2) every two or three hours are indicated. It may be combined 
with bismuth subcarbonate, grain v (0.3) every three hours. 

In older children this mode of treatment has lately given good 
results. I have had no experience with the administration of lead 
salts. In the acute cases the internal administration of preparations. 
such as tannigen, is irritating. 

Enemata. — Rectal enemata should be employed with care in the 
treatment of colitis or dysentery. Unless caution is exercised, their 
use is in many cases followed by an exacerbation or perpetuation of 
symptoms. The most useful form o( enema is the warm ( L08°- 1 L0° 
F., 42.2°-43.3° C.) saline (Cantani) solution. Fully a quart of 
fluid is allowed to flow into I he gut. The greater part of it returns. 
but I believe that if a portion o( this solution is retained it aeis in 
the manner of enteroclysis and supports the patient. These enemata 
are given three times in the twenty-four hours, for a day or two: they 



534 DISEASES OF THE STOMACH AND INTESTINES. 

are subsequently given twice a day, and finally, as the symptoms sub- 
side, only once a day. I have never been able to convince myself 
that silver nitrate (1:1000) or tannic acid added to the enemata is 
of value. On the contrary, I believe that in cases in the acute stage 
these medicated enemata are distinctly irritating. In the later stages 
of the disease, small quantities of fluid blood are passed with the 
faecal movements, tenesmus being present ; small enemata of silver 
nitrate (1:1000) given low down twice daily cause cessation of the 
bleeding which is due to the presence of ulcers low down in the 
rectum. In the subacute stage, the enemata will often be followed by 
an exacerbation of bloody mucous passages. Under these conditions 
it is well to discontinue the enemata and to watch the results of the 
suspension of local treatment. 

Serum. — The serum devised by Flexner, though protective in 
animals against infection, is not effective in the human subject. 

Amoebic Dysentery (Amoebic Colitis). — Amoebic dysentery is not, 
strictly speaking, a disease of infancy and childhood. It is caused 
by the Amoebae coli of Losch. Of 35 cases reported by Harris, 4 
were under ten years of age. Amberg has recently published 5 addi- 
tional cases. I have seen two cases in my hospital service, one in a 
boy 8 years of age, another in a girl 11 years old. The etiological 
factor is the Amoebae coli, which are found in large numbers in the 
movements. With the amoeba, Charcot-Leyden crystals are found in 
most cases. The cases published by Amberg were of a mild type, 
and seemed in no way to differ in symptomatology from the form of 
the disease seen in the adult subject. There were diarrhoea of a 
bloody character, tenesmus, and in some cases fever and prostration. 
As many as from four to six movements containing blood and mucus, 
and microscopically eosinojDhile cells, were passed in twenty-four 
hours. 

After the acute symptoms subside there may be recurrences in the 
form of attacks of diarrhoea with blood and mucus in the evacuations 
and the appearance from time to time of the amoebae in the stools. 

Diagnosis. — The diagnosis is made from the presence of the 
amoebae in the movements. Bloody passages containing Charcot- 
Leyden crystals should cause the physician to entertain a suspicion 
of the presence of this affection. 

Other amoebae, such as the Monocercomonas hominis (Grassi), 
have been found in the movements of infants suffering from diarrhoea. 
Epstein describes an epidemic of diarrhoea in which the monocer- 
comonas abounded in the movements. He thinks that in this epi- 
demic the diarrhoea was caused by well-water which contained the 
amoebae. I have found the Monocercomonas hominis in the move- 
ments of infants who were suffering from diarrhoea, but also of those 



DISEASES OF THE STOMACH AND INTESTINES. 535 

whose bowels were not in an abnormal condition. The role of the 
monocercomonas as an etiological factor in the causation of these 
diarrhoeas is not understood. It is doubtful whether they have any 
causal connection with the diarrhoea. 

Treatment. — The treatment consists in dieting on a fluid diet, the 
administration of quinine internally, and injections in the rectum of 
solutions of quinine 1 in 500. 

Constipation in Infants and Children. — Constipation may be 
classified as congenital and acquired. 

Congenital Constipation. — Congenital constipation is noticed imme- 
diately after birth, or in the days subsequent to it. The causes of 
congenital constipation are generally an absence of the anus or its 
occlusion by a thin membrane, or by a thick, hard membrane resem- 
bling the skin ; or there may be an anus and a shallow or deep cul-de- 
sac leading from the anus for some distance into the rectum, or this 
may be occluded at a varying distance from the external orifice. The 
rectum may be occluded by one or several membranes. Its walls may 
be thickened, so that meconium or faeces cannot pass ; or its walls may 
be agglutinated. The rectum, as has been stated, may end at some 
distance from the anus in a blind cul-de-sac, and from this point 
upward the rectum may either exist in its normal calibre, or may be 
simply indicated by a fibrous cord; in other words, there may be a 
congenital absence of the rectum. The rectum may end in a preter- 
natural opening into the bladder, the urethra or vagina, or may, by a 
common opening, a sort of cloaca, terminate in the perineum through 
the urethra or vagina. In such cases there is scarcely constipation, 
but rather a difficulty in voiding the faeces. There may be, as has 
been intimated, partial or complete absence of the rectum or colon ; 
or a large part of the larger bowel may be absent, or it may be stenosed 
in part of its extent and dilated in another part. It may be abnor- 
mally contracted. The colon or any part of it may be rudimentary. 
There may be obstruction, as in the rectum, in any part of the course 
of the colon. There may be a congenital occlusion of the ileocecal 
valve. 

Jacobi has described a case of congenital constipation due to mis- 
placement of the large gut and inordinate dilatation of this visens. 
In some cases of congenital malformation the small intestine may be 
entirely obliterated; or the small intestine in part of its extent may 
be normal, especially the duodenum; whereas the ileum may be rudi- 
mentary and (he large gul enormously dilated. There are cases on 
record in which there was no connection between the large and the 
small intestine, and there may be congenita] stricture in any pan oi 
the small intestine, either the duodenum or the ileum: or there mav 



536 DISEASES OF TEE STOMACH AND INTESTINES. 

be an obstruction due to a small diaphragm extending into the lumen 
of the intestine in any part of its course. 

It may be seen from a simple enumeration of the causes of con- 
genital constipation that the conditions found are extremely varied, 
and in most cases cannot be remedied by surgical means unless the 
obstruction diagnosed is low down in the rectum or sigmoid flexure, 
and exists without any accompanying deformity of the rest of the 
intestine. A congenital absence or rudimentary condition of the 
small or large intestine must eventually prove fatal. The symptoms 
of all the cases recorded of congenital constipation are those of obstruc- 
tion, in the end resulting in rejection of all fluids, vomiting, and 
ending fatally if unrelieved. A further discussion of this form of 
constipation is scarcely within the scope of this treatise. 

Acquired Constipation. — Acute. — Acute constipation is really a 
surgical disease, and is caused in infants and children by some acute 
obstruction of the gut, such as intussusception, volvulus, strangula- 
tion, through a slit in the omentum, strangulation by peritonitic 
bands, or by the persistence of Meckel's diverticulum; hernia of all 
kinds, strangulation or paralysis of the intestine as a result of trau- 
matism. Peritonitis may cause acute constipation, and with this we 
must consider diseases such as appendicitis. 

Foreign bodies may obstruct the lumen of the bowel. Watkins 
relates the case of a boy, ten years of age, who had swallowed an 
immense quantity of figs, which obstructed the lower part of the intes- 
tine near the anus, and had to be removed by surgical means before 
movements were established. J. Lewis Smith relates the case of a 
girl, four years old, in whom acute constipation developed suddenly 
as the result of the impaction of a mass of intertwined worms in the 
intestine. This acute obstruction was attended by distention of the 
abdomen and great suffering. A large gall-stone is mentioned as 
obstructing the ileocecal valve, and in this way suspending for a 
time the passage of faeces through this structure. 

The diagnosis of acute constipation presupposes a diagnosis of 
the primary causal condition, and this can only be made by a careful 
study of the case. Cases of intussusception, volvulus, strangulation, 
either by bands or hernia or forms of peritonitis, will give symptoms 
of these diseases. It is scarcely the place here to enter upon these 
fully. In those cases in which worms cause obstruction, the diagnosis 
can only be made after relief has been established by passage of the 
corpus delictu, unless enough faeces are voided to examine the same 
for eggs of the worms. 

Chronic. — Chronic constipation may be dependent upon obstruc- 
tion of the large or small intestine in any part of its extent, either 
by morbid growths, sarcomata, carcinomata, or tuberculous perito- 



DISEASES OF THE STOMACH AND INTESTINES. 537 

nitis. The latter form of obstruction by tuberculous masses is of 
especial interest, inasmuch as these cases form a part of the sympto- 
matology of tuberculous peritonitis. I saw a case of tuberculous 
peritonitis in which large masses were palpable in the abdomen, and 
in which one of these masses involved the descending colon to such 
an extent as to almost completely occlude its lumen. 

Anal fissure is a common cause of chronic constipation in infants 
and children. In these cases there is always a history of great pain 
when the movement is passed, and for some time afterward. - Blood 
may accompany movements when there is a fissure of the anus. 
Children suffering in this manner do not void a movement for days, 
and when the movement is passed the suffering sometimes is intense. 
In some children there is a spasm of the anus due to a nervous condi- 
tion, and sometimes brought about by an excoriated state of the anus. 
Examination does not reveal any fissure, but there is a distinct spasm 
of the sphincter which prevents the successful evacuation of the 
rectum. In all of these cases chronic constipation is really a surgical 
disease, and can only be relieved by surgical measures. In some 
cases caused by cancerous, sarcomatous, or tuberculous growths the 
surgeon is unable to relieve the patient. Constipation caused by anal 
fissure, spasms of the sphincter, or excoriations around the anus 
yields more successfully to surgical treatment, which is the same as a 
treatment for similar conditions in the adult, viz., forcible dilatation 
of the sphincter. 

Chronic Habitual Constipation. — The next form of chronic con- 
stipation is that which most interests the general practitioner, and is 
known as chronic habitual constipation. Of all the conditions within 
the domain of pediatrics habitual constipation is the most difficult 
of management. It is not always possible in these infants and chil- 
dren to fix on the absolute causes of a constipated habit. 

Etiology. — Infants at the breast may be constipated from birth, 
though normal in every other respect, and continue this habit through- 
out childhood. In many of these cases the mother is of a constipated 
habit. Some signs of rachitis may be present in certain cases. In 
these cases, however, it is reasonable to conclude that the mother's 
milk is lacking in some element, such as fat, which tends to perpet- 
uate the constipation. In other cases the milk may be absolutely 
normal, and still a condition of atony of the gut of an hereditary type 
may exist. 

Constitutional Dyscrasia. — Rachitis, when marked, is associated 
with constipation in a large proportion of eases. In a manner similar 
to the bones, so the muscular apparatus lacks tone, and ii is not sur- 
prising that with the muscular atony the glandular elements ot the 
gut should be deficient in furnishing elements necessary to a normal 



538 DISEASES OF THE STOMACH AND INTESTINES. 

maintenance of the functions and evacuation of the intestinal contents. 

Heredity. — Heredity has been named as a cause of constipation 
in breast-fed infants, and it is not infrequent to meet the same condi- 
tion, possibly due to the same cause, in bottle-fed infants. 

Incorrect Feeding. — Incorrect feeding is certainly one of the most 
frequent causes of constipation in artificially fed infants and children. 
Some infants who have been started on very dilute modifications of 
milk are constipated from the beginning, or their constipation has 
been fostered by heating the milk to a greater or less degree, and in 
these cases the constipation, if allowed to persist for any length of 
time, is perpetuated into the period of childhood. 

In other cases raw milk will cause constipation. In older chil- 
dren a simple diet of two or three articles of food, which have been 
religiously adhered to from the time of weaning to a varying period 
of childhood, is the direct cause of constipation. There has been a 
failure in these cases to give an appropriately mixed diet. I have 
seen constipated children, at varying periods of childhood, who have 
been kept systematically on a diet of milk and fruits, for fear that 
any other article of diet would cause intestinal disturbance. The 
result has been an inordinate constipation of chronic duration with 
accompanying symptoms. 

Symptoms. — One can scarcely speak of the symptoms of constipa- 
tion which in itself is a symptom of disturbed intestinal conditions 
and metabolism. There are certain features, however, of the move- 
ments of constipated infants and children which are of importance. 

Stools. — The intestinal movements of infants suffering from con- 
stipation may be hard and formed, or may be unformed and dry. 
Ordinarily a healthy infant has two, three, or four movements daily, 
the rule being two. A healthy infant may have six movements a 
day and still be within the limits of health. We judge by the char- 
acter rather than by the number of the movements. The normal 
characteristics of intestinal evacuations have been dilated upon else- 
where, and the reader is referred to the section treating of this subject. 

In constipated infants the movements consist almost entirely of 
marble-like masses, resembling those seen in the lower animals. They 
rarely have a movement unaided. They have great pain in passing 
the fa?ces, and in time develop fissuration of the anus to a greater or 
less extent, with accompanying bleeding due to the stretching of the 
fissure. In other cases this bleeding is accompanied by slight pro- 
lapsus of the gut during the movement, which often creates the im- 
pression that the infant is suffering from hemorrhoids. Many of 
these constipated movements are coated with mucus, or mucus is 
voided after the movement is passed. These masses are not mem- 
branous, and if examined will be seen to be composed mostly of mucus. 



DISEASES OF THE STOMACH AND INTESTINES. 539 

Other Symptoms. — Constipated infants after a time develop a 
pallor and anaemia whieh is characteristic, and seem to suffer from 
intestinal absorption and toxsemia which results from time to time in 
periodical attacks of vomiting, discussed elsewhere. These children 
also complain from time to time of a vertigo and nausea, especially 
in the morning. Many children who are thus constipated will reject 
their food in the morning. They lose their appetite and have all the 
symptoms of intestinal intoxication. 

Treatment. — The treatment of constipation is dietetic and medic- 
inal. If the infants who are constipated are fed at the mother's or 
nurse's breast, the bowels of the mother or nurse need regulating, and 
they should take regular exercise. In many cases a nutritious diet 
to the mother or nurse will cause the milk to change in its composi- 
tion, containing more fat, and thus improve the condition in the 
infant. On the other hand, an increase of the fats will decidedly 
aggravate the constipation in some children. Therefore we diminish 
the fat of the milk in such cases. If artificially fed children are 
constipated, the heating of the milk should be stopped. If for some 
reason milk must be pasteurized or sterilized, the time of heating 
should be reduced to a minimum. Constipated infants may be fed 
on raw milk if the milk is fresh and carefully kept. The formula 
should contain sufficient fat to make the diet nutritious, but the fat 
should not form more than 4 per cent, of the mixture. As a rule, 
artificially fed infants do well on a smaller quantity of fat than the 
average breast-fed infant. Thus 2.5 to 3 per cent, of fat meet the 
requirements of most infants. Some infants fed on raw milk and 
an increase of fats become more constipated. The stools are hard 
and dry and there is an unmistakable anaemia. 

Children from the sixteenth month to the second year who suffer 
from constipation should be gradually weaned to a mixed diet. In 
many cases this procedure will regulate the bowels. The children 
should be given green vegetables, such as peas and spinach, in the 
form of a puree. The diet should include cereals of the various 
varieties, especially wheatena, oatmeal, granum, and rusk (Zwieback"). 
The milk should be given raw with a moderate mixture of cream. 
Fruit, such as oranges, raw apples, and pears, is also given in moder- 
ation. If the constipation cannot be remedied by these measures. 
recourse is had to medicinal treatment. 

Cathartics. — At best, cathartics are a makeshift. Some older 
children will do well with a small dose, grain 1 i,-,o (0.0004)- of 
strychnine once a day, and a simple cathartic, such as the aromatic 
fluid extract of easeara, twice or three times a week. A child two 
years of age may be given ii[ \\ to xxx ( L.O to 2.0) once a day. The 
preparations of rhubarb are useful, but do not give uniformly satis- 



540 DISEASES OF THE STOMACH AND INTESTINES. 

factory results. The mercurial cathartics are available only once a 
week in the majority of cases. We are thus reduced to the necessity 
of giving suppositories or enemata. With very young infants a small 
cylindrical piece of soap inserted with oil into the rectum once a day 
will be effective. With older children the glycerin suppository given 
every other day is very useful. 

Enemata. — In many cases it is necessary to give enemata : to 
younger infants they are given once a day; to older children an 
enema is given twice a week. When the child becomes pale and 
listless a brisk cathartic aided by a large high enema is given. In 
this way an attack of vomiting may be avoided. 

Massage. — Massage of the abdomen gives very unsatisfactory 
results. Gymnastics or calisthenic exercises in the morning after a 
bath are useful in some cases. 

Habits. — The inculcating of a habit of evacuating the bowel at 
regular intervals daily will do much toward overcoming constipation. 
The children are placed on the toilet and are taught to keep their 
minds on the object to be attained. The results in some cases are 
gratifying. 

Useful f ormulse are the following : 

1. Pulv. glycyrrhizae comp. . . . 3ss to 3j (2.0 to 4.0) as necessary. 

2. Infus. sennge comp 3j~3ij (4.0-8.0) as necessary. 

3. Podophyllin gr. ij (0.12). 

Syr. rhei arom ^J (60.0). 

Sig. 3j (4.0) pro dosi. 

Congenital Dilatation of the Colon, With or Without Hyper- 
trophy of Its Walls (Hirschsprung's Disease). — This deformity is 
one of the rarer causes of habitual constipation in infants and chil- 
dren. We distinguish three forms of this condition. 

a. In this form there is an increase in the length of the colon 
descendens and the sigmoid flexure. As a result of the increased 
length of the colon this portion of the intestine bends two or three 
times on itself. There is a stagnation of the faeces and consequent 
constipation. Toxaemia results and emaciation follows. With the 
above there are symptoms of fermentation in the gut, and constipation 
alternates with diarrhoea. The diarrhceal movements are foul, con- 
taining mucus and blood. There is some meteorism. 

Prognosis. — The prognosis of this form is not bad, provided a 
complicating colitis does not ensue. As the child grows older the 
above symptoms improve and normal conditions ultimately supervene. 

b. In this class of cases the colon is not only lengthened and 
dilated, but its walls are thickened. Such are the cases of Mya, 
Formad, Griffith, and Hirschsprung. According to Concetti, the 
mucosa is not only thickened, but the connective tissue and muscular 



DISEASES OF THE STOMACH AND INTESTINES. 



41 



coats of the intestine show the same changes, and the arteries are the 
seat of arteritis. The cases belonging to this class in the literature 
range from eight to fifty years of age. It is in this set of cases that 
stagnation of the faeces is accompanied at times with ulceration of 
the gut. 

c. In this class of cases there is a combination of the dilatation of 
the colon with thin walls; or the colon may be normal in its lower 
portion and slightly ectatic, with hypertrophied walls above. 

Symptoms. — The symptoms of the last two sets of cases are more 
severe in the younger and milder in the older children. They are 
severe if the condition has lasted for two or three years, and milder if 
the patient has survived until the tenth or twelfth year. From the 
second to the fourth day after birth great meteorism appears. No 
meconium is passed for some time, and there is no stenosis of the 

Fig. 111. 




Infant nine weeks old. Congenital dilatation of the colon, strictures in the sig- 
moid flexure. Enormous, abdominal distention ; inordinate constipation ; coils of large 
intestine visible on the abdomen. Eventual death 



gut; laxatives succeed in bringing away only a small amount of 
meconium or fgeces. The constipation is very obstinate, the fseces 
are foul-smelling, and from time to time colitis may supervene, or 
every eight to thirty days hard, malodorous masses are evacuated with 
slime and blood. There is a condition of an autointoxication ami 
a resultant cachexia. The abdomen becomes enormously distended, 
and the coils of the intestine can be made out on the surface ( Fig. Lll). 
The children die during the first and second years oi' life, either 
through cachexia or perforation oi' the gut. Of the 21 eases collected 
by Concetti only :3 lived. One was a case of his own, and another 
that of Osier; in both an artificial amis was made for the relief o( 
the condition. Colitis, with or withoul perforation o( tin- intestine. 



542 DISEASES OF THE STOMACH AND INTESTINES. 

is the most frequent cause of death. The remaining cases die of 
cachexia. 

Treatment. — The first class of cases are treated in much the same 
manner as is constipation. In the second and third forms surgical 
interference is indicated as soon as the diagnosis is made. The colon 
is resected. Thus far surgical interference has not been attended 
with great success. 

Acute Intestinal Obstruction (Intussusception). — Intussuscep- 
tion, according to Treves, is the prolapse of one part of the intestine 
into the lumen of an immediately adjoining part. It causes more 
than one-third of all the varieties of obstruction of the gut. 

Varieties. — Invagination of the gut may take place in any part, 
from the duodenum to the rectum. There are the following forms: 

Enteric. — The enteric form, which may involve any part of the 
small intestine, but which most commonly involves the lower part of 
the jejunum or the ileum. 

Colic. — The colic form, which may involve any portion of the 
colon. 

Ileoccecal. — The ileocecal, which is the most common form. 

In the ileocecal variety the ileum and caecum pass into the colon, 
the valve preceding and forming the apex of the intussusception. In 
the ileocolic form, the valve remains stationary and the ileum passes 
into the colon. In the latter form there is an invagination of the 
caecum and colon, of a secondary character. 

Etiology. — Xothnagel demonstrated that intussusception is caused 
by irregular muscular action in the wall of the intestine ; in acute 
intussusception this is of a spasmodic character. In 50 per cent, of 
the cases little is known of the exciting cause. 

Diarrhoea, the various forms of enteritis, polypi, and diverticula, 
improper food, traumatism, and exposure to cold, have all been 
regarded as exciting causes. Typhoid fever and pertussis have been 
complicated or followed by intussusception. I have recently seen a 
case following typhoid fever in a boy three years old. 

Meckel's diverticulum and the appendix have been the cause and 
seat of intussusception. In the latter case the inverted appendix 
caused ileocecal intussusception. 

Frequency. — Intussusception is more common in males than in 
females. The disproportion diminishes after the first year of life. 
Fifty per cent, of all the cases occur before the tenth year, and chiefly 
in individuals who are not in good physical condition (Treves). In 
the cases that I have seen, the infants were not noticeable for being 
in previous delicate health or may have been robust infants at the 
breast in whom there has been a previous history of intestinal 
indigestion. 



DISEASES OF THE STOMACH AND INTESTINES. 543 

The youngest case I have met was five and a half months of age. 
This infant was breast fed, had suffered with colic, and had had green 
movements from birth; there was an ileocecal invagination eight 
inches in length. 

Symptoms. — The onset is sudden in 75 per cent, of the cases; in 
the colic and rectal varieties it may be gradual. In many cases the 
disease makes its appearance while the infant is nursing or during 
sleep. The patient, being attacked with pain, suddenly awakes from 
sleep with a cry and begins to vomit ; on the same day or the follow- 
ing day a bloody movement appears, the amount of faeces being small. 
In a few cases there are no fsecal evacuations. If the case is progres- 
sive, the pain returns in paroxysms, the hemorrhagic movements are 
repeated, and the vomiting keeps pace with the increase of the obstruc- 
tion. The general condition of the patient grows worse ; apathy and 
collapse ensue. I have seen cases begin with a mild diarrhoea ; the 
pain suddenly appears, and also the hemorrhages from the bowel, the 
infant at once going into collapse. 

There is apathy due to intestinal intoxication from which it is 
difficult to rouse the patient. If the case continues to progress with- 
out relief the movements become frequent, exhaustion increases, and 
finally death from asthenia results. The pain is great at the onset, 
usually reaches its maximum intensity within a short time, and then 
gradually subsides. It is of a paroxysmal character and is colicky 
during the advance of the invagination; as adhesion takes place or 
gangrene occurs it diminishes. The intervals between the paroxysms 
of pain are at first of considerable length ; later they become shorter. 
The pain is most severe in the ileocsecal form, and is in all forms 
caused by irregular intestinal peristalsis. 

Vomiting. — Vomiting is not so prominent a symptom as in other 
forms of intestinal obstruction (Treves). In 75 per cent, of the 
cases it comes on early with or directly after the pain. It may not 
recur for hours. In a child taken with sudden pain of a colicky char- 
acter, vomiting, and bloody stools, the vomiting recurred only twice 
within twenty-four hours. It is apt to be less violent as long as there 
is not complete obstruction of the gut; in other words, it is more 
marked in those cases in which no faeces pass. As long as the pain 
recurs in paroxysms (progression of the intussusceptum) the vomit- 
ing is not apt to be marked. The vomited matter is composed of the 
stomach contents and is biliary; stercoraceons vomiting was found 
late in only 25 per cent, of Leichtenstern's cases: Gibson also found 
it to be rare and Late, If stercoraceons vomiting was present, ii 
appeared from Hie fourth lo (he seventh or to the fourteenth day. In 
the case referred to, in the infant of five and one-half months, it 
appeared during the tirst twelve hours of the disease. 



544 DISEASES OF THE STOMACH AND INTESTINES. 

The condition of r the bowel is important. It is generally stated 
that constipation occurs from the outset ; this is not universally true. 
Cases in which constipation exists throughout, that is to say, in which 
no faeces whatever are passed, are not common, and form only 30 per 
cent, of the total number. Diarrhoea is the common condition at the 
outset ; as the obstruction increases, the amount of fseces in the stools 
diminishes, and finally only mucus and blood are passed. 

The most important symptom in connection with the bowels is 
hemorrhage. Hemorrhage from the bowel, in connection with pain 
and other abdominal symptoms, is considered by Gibson as pathog- 
nomonic. It was present in 80 per cent, of the cases tabulated by 
Leichtenstern. As a rule it is considerable. It is said by Treves 
to have been in some cases so great as to cause death. The blood and 
faeces have a cadaveric odor, which, however, is not always, as some 
writers affirm, a sign of gangrene. I have perceived this odor in an 
intussusception which operation showed not to be the seat of gan- 
grene. It is caused by decomposition of the blood in the gut. 

The temperature is normal, slightly subnormal, or slightly ele- 
vated. There may be a slight elevation of temperature without peri- 
tonitis. The quantity of urine may as in other forms of intestinal 
obstruction be diminished. 

Tenesmus. — Tenesmus is present in 55 per cent, of the cases; it 
depends more or less on the presence of the intussusception in the 
rectum. It is usually an early symptom in the rectal form, and is 
more common in the ileocsecal variety than in the enteric. 

The abdomen is not at first distended; it may, on the contrary, 
be retracted; if tympanites occurs at all, it does so late and in the 
presence of a general peritonitis. Palpation of the abdomen is at 
first well borne, but after a time there is sensitiveness. 

Tumor. — A tumor felt through the abdominal wall or in the 
rectum is of the greatest value in the diagnosis. It cannot be felt 
if the intussusception is in the hepatic or splenic flexure of the colon. 
It is variable in distinctness, and is most frequently felt in the region 
of the descending colon or of the sigmoid flexure. 

Infants below one year of age who were brought under my obser- 
vation early presented a distinct tumor in the region of the ascending 
and transverse colon if the intussusception was ileocaecal. Gentle 
superficial palpation is more effective in infants than rude examina- 
tion; the latter is apt to cause crying and abdominal rigidity. It is 
hard and resistant, and rarely more than six inches long. It is often 
said to be sausage-shaped, but the statement is misleading. The 
tumor is rarely felt in the ileocsecal region, for the reason that the 
intussusception in this locality is small, and is that of a small gut 
inside of a large one. In one-third of the cases the rectum, if exam- 



DISEASES OF THE STOMACH AND INTESTINES. 545 

ined, shows the presence of the intussusceptum. The rectal tumor is 
commonly found in children, because in them the colon is mobile. 
In very early cases I have not found a rectal tumor. The intestine 
may reach the anus as early as the second day, the average time being 
the seventh day. It may protrude from the anus from three to eight 
inches, and may be in a gangrenous state; under these conditions it 
has been mistaken for a polypus or hemorrhoid. 

Prognosis. — As regards duration, there are three varieties of intus- 
susception — the ultra acute, the acute, and the subacute. The ultra 
acute cases are exceedingly rare. Leichtenstern found only 5 of this 
form in a total or 7269 cases ; 4 of the 5 occurred in infants less than 
a year old. All were fatal. 

The rate of mortality in intussusception, excluding the ultra acute 
forms, varies as given in the statements of different authors. Gib- 
son's statistics place the mortality at 53 per cent. It varies with the 
age of the patient, the duration of the disease before operating, and 
the success in reducing the intussusception. Intussusception is ex- 
tremely fatal in infants under the first year. 

If the diagnosis is made early I have found the prognosis in 
infants below one year of age not as bad as some writers would lead 
us to suppose. According to Treves, the mortality under one year 
of age is 80 per cent. On the other hand, if we study the cases as 
Gibson has done, we find that the cases operated on during the first 
day of the disease had a mortality of 41 per cent. ; those on the fourth 
day, 72 per cent. The reducible cases showed a mortality of 38 per 
cent. ; the irreducible, of 88 per cent. 

Diagnosis. — From the studies made by Gibson, it may be seen 
that, in children, a bloody discharge with abdominal pain of a 
paroxysmal nature is almost pathognomonic of intussusception. The 
presence of a tumor fixes the diagnosis absolutely. Faecal vomiting 
is of very little value as a diagnostic sign. It is very infrequent, and 
is in any case present only late in the disease, when occlusion of the 
gut has occurred. 

If enteritis exists in a young infant, it is often difficult in the 
absence of any abdominal or rectal tumor to make a diagnosis. The 
course of the case will guide the physician. In dysentery the hemor- 
rhage from the bowel is not great; it is composed of blood-tinged 
mucus with faeces. Cases of scurvy may simulate intussusception if 
bloody discharges appear with the intestinal movements. In these 
cases the amount of blood voided per rectum is fully as great as in 
cases of intussusception. In scurvy, however, there is faecal matter 
in the movements, in the cases coming under observation o( the author, 
as also signs of scurvy, such as tenderness of the bones and spongy, 
bleeding gums. Appendicitis has been mistaken for intussusception. 

35 



546 DISEASES OF THE STOMACH AXD INTESTINES. 

It frequently occurs with it, and thus obscures the picture. Peri- 
tonitis can hardly be mistaken for intussusception. In peritonitis 
the pain is continuous and there is tympanites, but no bloody dis- 
charge. Peritonitis is, however, a late symptom. Tuberculous peri- 
tonitis is sometimes mistaken for intussusception. In tuberculous 
peritonitis the symptoms are not progressive, and also there is not 
likely to be a bloody discharge. 

The case following typhoid fever, to which I referred, simulated 
a hemorrhage from a typhoidal ulcer. A careful examination under 
an anaesthetic cleared up the case. In complete relaxation under 
anaesthesia, a tumor could be felt in the caecal region of the ascend- 
ing colon. The result of examination was verified by operation. In 
all doubtful cases in which the restlessness of the child interferes 
with a careful examination an anaesthetic should be given. There 
is a characteristic condition which in some cases can be detected by 
examination. As the finger is inserted into the anus the rectum is 
felt to be inflated. This is due to traction on the gut by the invagi- 
nation. I have found this inflated state of the rectum in two infants 
suffering from intussusception. 

Spontaneous Cure. — There is little doubt of the possibility of spon- 
taneous recovery in invagination; such cases have been seen by com- 
petent observers. Henoch has seen typical intussusception retrograde 
and the patient recover. There is another mode of recovery which 
occurs in cases of irreducible intussusception : the intussusceptum 
sloughs off and is passed per anum. This occurred in 43 per cent, 
of the unrelieved cases (Leichtenstern), but in 40 per cent, of these 
the patient succumbed to general sepsis with or without peritonitis or 
to subsequent obstruction of the gut from swelling after the gan- 
grenous portion had sloughed away. Henoch reported a case of this 
kind. 

Treatment. — The diagnosis of intussusception once made, the case 
is one for surgical interference. The sooner surgical treatment is 
begun, the better the chances of recovery. Injections of air, gas under 
pressure, and enemata of water and oil have been tried, -with, some 
measure of success. Their use, however, delays the radical treatment 
and reduces the chances of ultimate recovery, and apparent improve- 
ment frequently gives way to an exacerbation of symptoms. Surgical 
aid then comes too late. 

The objections to the treatment by injection are as follows: the 
intestine is viable in these cases, and is liable to be ruptured by injec- 
tion of gas or air under pressure ; an enema of water under only four 
feet of pressure has been known to produce this result. Snow published 
a case in which an injection of oil was made; postmortem the oil was 
found above the point of obstruction. The enema may thus pass 



DISEASES OF THE STOMACH AND INTESTINES. 547 

through the lumen of the gut without relieving the intussusception. 
Enemata should be given, if at all, during the first 24 hours, and 
should.be allowed to flow into the rectum under very low pressure. 
The amount of fluid varies ; certainly not more than a quart should 
be given. The fluid, a saline solution at 100° F. (37.7° 0.), is 
allowed to remain in the rectum for ten minutes, the patient being 
under an anaesthetic. A Davidson syringe should not be used. The 
ordinary fountain bag irrigator is best for this purpose. If one 
enema fails and the diagnosis is moderately certain there should be 
no delay in seeking surgical assistance. 

Appendicitis (Perityphlitis; Paratyphlitis) Anatomical Pecul- 
iarities. — Yallee examined the appendix in 100 infants and children 
postmortem. He found that in fully 75 per cent, the caecum is situ- 
ated above the anterior superior spine, on the right side, a position 
higher than that occupied in the adult. It is above the plane of the 
anterior superior spine of the ileum, is almost 5 centimetres long, and 
has a general longitudinal ascending or descending direction. In 
one case the appendix was situated entirely to the left of the median 
line, there being no transposition of the other viscera. Knowledge 
of these facts is of importance in the examination for the appendix in 
conditions of disease. I have frequently succeeded in palpating the 
normal appendix at one side of the caecum. It is felt as a cylindrical 
body having the diameter of a quill. 

Acute Appendicitis. — Frequency. — Although the statistics show- 
ing the frequency of appendicitis in infancy and childhood vary with 
the number of cases collected by each author, the combined statistics 
of Matterstock, Fitz, Sonnenburg, and Nothnagel, show that the dis- 
ease is not very frequent before the tenth year. Only 8 per cent, of 
the cases occur at this age. It may occur in early infancy. Savage 
records a case in an infant two months old; Demme also record- a 
case in a very young infant. 

The literature shows occasional cases at all periods of infancy. 
Among the cases collected and tabulated from the service of my col- 
leagues, Gerster and Lillienthal, at the Mount Sinai Hospital, there 
is one of an infant one year of age. Of 50 cases of appendicitis in 
children taken from the service of these surgeons, 1 occurred in an 
infant one year of age, 17 from the third to the sixth year, and 32 
from the sixth to the tenth year of life. Thus in a statistical collec- 
tion of cases occurring in children, only one-third occurred before the 
sixth year of life. 

Varieties. — The forms of the disease are the same as in the adult 
subject. The perforative form seems \o be the most common among 
children. Tims of 50 casts coming to the hospital for operation, 31 
were perforative with or without abscess, !> were of the gangrenous 



548 DISEASES OF THE STOMACH AND INTESTINES. 

variety, and 6 of the catarrhal form. It will thus be seen that in 
children the tendency in this disease as in others, snch as pleurisy, is 
toward suppuration and the formation of abscess. 

Symptoms. — The symptoms will vary with the variety, whether 
catarrhal, perforative, or gangrenous. 

Catarrhal Form. — In the catarrhal form the patient is, after 
some indiscretion in diet, seized with colicky abdominal pain, vomit- 
ing, and some fever. In other cases the children simply complain of 
pain which is not sufficiently severe to prevent their being up and 
about. The pain is not always located by the patient in the appendix. 
When the patients are in the recumbent posture, the right knee may 
be flexed and the thigh flexed on the abdomen ; when they walk, they 
do so in a bent position, favoring the affected side. Physical exami- 
nation reveals a localized resistance or tenderness in the right iliac 
fossa. In some cases there is distention of the caecum with faeces, in 
others I have felt the appendix and the caecum matted together in a 
mass of the size of the index finger. 

The pain is not always referred to the iliac fossa, but may be 
distinctly located around the umbilicus or over the lower part of 
the abdomen. 

It may not always be possible to palpate the appendix, which may 
be behind the caecum. Under such conditions no intumescence will 
be found. McBurney's point will be considered in the diagnosis. 

The history of many of the catarrhal cases is one of recovery 
under careful treatment. The fever subsides or may never have been 
above 101° F. (38.3° C.) ; the pain also subsides, and in from a few 
days to a week the patient is apparently well. Attacks of this kind 
may recur. 

Perforative or Suppurative Form. — In the perforative or suppu- 
rative form the symptoms are more violent. In this form also the 
onset of the disease seems to date from some indiscretion in diet. 
The patient is seized with sudden sharp pains in the abdomen, accom- 
panied by vomiting, fever, and rapidity of pulse. The pain is located 
either in the upper or the lower part of the abdomen, or in a few 
cases in the right iliac fossa. After one or two attacks of vomiting 
this symptom may subside and not recur until the second or third 
day, when perforation occurs. Tympanites occurs early and may set 
in after the second day of the disease. The pain and tympanites 
cause an increase in the respiratory movements, which are shallow. 
The patients lie in the recumbent posture. The escape of gas and 
intestinal contents, if perforation occurs, causes a disappearance of 
the liver dulness, with peritonitis and a formation of fluid in the 
peritoneal cavity with a movable dulness in the flanks on percussion. 
The pulse is at first rapid and thready, and quickly mounts above 



DISEASES OF TEE STOMACH AND INTESTINES. 



49 



120 after perforation has occurred. The prostration is great, and in 
some cases of a septic type jaundice is present. 

Gangrenous Form. — In the gangrenous form the symptoms are 
very similar to those of the perforative form, but are very much inten- 
sified. It is not possible to tell from the symptoms whether the process 
is gangrenous, simply perforative, or catarrhal followed by abscess. 

Course. — In both the perforative and the gangrenous cases in chil- 
dren as in the adult, localized adhesions may form with a small or 
large collection of pus or several foci of pus. In other cases a gen- 
eral peritonitis follows the perforation. In children, as in adults, 
the moment of perforation is followed by a temporary fall in the 
temperature and a cessation in the pain and vomiting, the pulse, how- 

Fig. 112. 




Method of examination of the region of the appendix vermiform is. 



ever, continuing rapid. The lull, however, is of short duration, and 
is quickly followed by an increase in the severity of the symptoms. 

Diagnosis. — The above outline gives very little idea of the great 
and sometimes insurmountable difficulties of diagnosis of appendicitis 
in young children. To guard against error, a very careful routine 
should be followed. The patient is completely undressed and lies in 
the recumbent posture, the shoulders being slightly raised. The phy- 
sician should stand or sit at the patient's right. The contour of the 
abdomen is noted. If it is normal and not distended, there is prob- 
ably no peritonitis. The abdomen is very gently palpated in different 
places to ascertain if there is distributed or localized tenderness. The 
left palm is then placed underneath the rigbt loin, and with the palmar 
surface of the fingers of the right hand the region of the appendix is 
gently palpated (Fig. 112). 

Superficial palpation is practised at first. The hand is then 
depressed deeper into the iliac fossa in search o( resistance or tumor. 



550 DISEASES OF THE STOMACH AND INTESTINES. 

The intensity of the pain caused by manipulation is carefully gauged 
by watching the face of the patient. The right iliac region having 
been carefully palpated, rectal exploration should be made in all 
doubtful cases. This is necessary in the cases in which a general 
tympanites or general abdominal tenderness makes the diagnosis 
difficult. With the well-oiled index finger of the right hand the 
rectum is explored as high up as possible. In young children this 
can be done without causing pain if gentleness and caution are exer- 
cised. If children are very intractable, this method of examination 
cannot be carried out. 

Rectal examination is exceedingly dangerous in those cases in 
which there is a localized abscess. Any careless manipulation may 
break up the delicate adhesions between the coils of gut and evacuate 
the abscess into the general peritoneal cavity. 

The following points are important in the diagnosis : 

Tympanites. — If the abdomen is distended and there is general 
pain with increase of the number of respirations, there is probably 
peritonitis localized or diffuse. In the latter case there is disappear- 
ance of the liver dulness if the tympanites is extreme. 

Percussion. — Percussion will sometimes, even in general peri- 
tonitis, give a localized dulness in the right iliac fossa. Localized 
pain and intumescence or a localized mass in the right iliac fossa are 
of great import. 

McBurney's Point. — McBurney's point is of less value in children 
than in the adult. In children, as will be seen from Yallee's work, 
the appendix is situated higher than in the adult, and McBurney's 
point is therefore too low for palpation. Some children complain of 
epigastric, others of umbilical pain, which is not so distinctly localized 
as in the adult. 

Fever. — The fever is of little value, there being nothing charac- 
teristic in the curve. The temperature may be normal or in severely 
septic cases slightly raised. After perforation, the temperature be- 
comes subnormal, as it does in the adult. 

Tuberculous Peritonitis. — Appendicitis in children may simulate 
tuberculous peritonitis. In the latter disease there is sometimes 
severe pain of the colicky variety. Tuberculous peritonitis and ap- 
pendicitis may be coincident. 

Pain. — Pain in appendicitis resembles very closely that in gastro- 
enteritis and dysentery. Griffith has published 2 cases of appendi- 
citis in children who had entero-colitis at the same time. 

Perinephritic Abscess. — I have had one case in which a peri- 
nephritic abscess simulated an appendicitis. The contrary may also 
occur. Appendicular abscess may simulate a coxalgia with abscess. 
I have seen a few cases of typhoidal affection of the appendix which 



DISEASES OF TEE STOMACH AND INTESTINES. 551 

for a few days simulated an appendicitis very closely, so as to mis- 
lead the surgeon into operating upon them. Appendicitis with in- 
vagination of the appendix into the caecum is a rare condition, as is 
also intussusception with appendicitis. In the typhoidal cases, a 
Widal reaction may be obtained, and will be of assistance in diagnosis. 
Care should be taken that a perforating typhoidal ulcer does not 
escape diagnosis. Intussusception will give the characteristic symp- 
toms of that condition. 

Lobar Pneumonia. — I have seen cases of lobar pneumonia of the 
lower lobe of the right lung, in which the pleuritic pain radiated 
down the right side into the iliac fossa. There were also epigastric 
pain and vomiting at the onset of the disease. The excessive rapidity 
of the respirations, the marked dyspnoea, and absence of tympanites 
and pain on deep pressure in the region of the appendix, led me to 
examine the lung. 

Prognosis. — Of the 50 hospital cases which I have tabulated above, 
only 3 recovered without operation; they were of the catarrhal 
variety. These figures give no accurate idea of the proportion of 
recoveries made under careful and conservative treatment in private 
practice. 

The mortality in the cases operated upon was 35 per cent. The 
rate is not high considering that many cases came under the knife 
later than would have been the case in private practice. On the 
other hand, it should be remembered that the rate of mortality is also 
influenced by the nature of the infection and the power of resistance 
of the patient. Thus cases with a gangrenous appendix died although 
operated upon on the second day; others of the same kind recovered 
although the disease had lasted from four to seven days before opera- 
tion. Some perforative cases died on the second or third day of the 
disease, while others recovered although operated upon from six to 
twelve days after the onset of symptoms. Gangrenous cases in this 
statistical table in children show a lower rate of mortality than those 
cases in which the appendix perforates, forms an abscess, and causes 
general peritonitis. 

Chronic Appendicitis. — This form of appendicitis occurs in older 
children. The symptoms are frequently mistaken for those of dys- 
pepsia. The history is much the same as in the adult. A child 
otherwise in good health has attacks during which there is abdominal 
pain not of great severity, accompanied, at times, by vomiting, but 
which may last for a few hours and disappear, leaving the patient 
well. The pain is very rarely referred to the appendix; ii is abdom- 
inal, the umbilical regioii being generally indicated as the scat of dis- 
comfprt. The temperature may reach 100 F. (37.7° C.) : the pulse 
in ;i child of eight years was 96 and regular. There is no vomiting 



552 DISEASES OF THE STOMACH AND INTESTINES. 

and no prostration. The pain is sufficiently severe to make the patient 
wish to lie down; it is not excessive when the appendix is palpated. 
The bowels are regular. The cases may in the intervals between the 
attacks show a slight intumescence in the region of the appendix, but 
nothing is felt in the rectum. The signs in the interval may be very 
indefinite or quite distinct. The caecum and appendix are felt to be 
matted together. 

Three cases in which there had been repeated attacks extending 
over a period of from one to two years, were operated upon for me 
by leading surgeons. The patients were girls between the ages of 
six and eight years. In each case there was evidence of a chronic 
catarrhal process. In one case the appendix contained a faecal cal- 
culus, in another there were constricting adhesions. 

Treatment. — The treatment of both acute and chronic appendicitis 
in infants and children does not differ from that followed in the adult 
subject. 

Rectum. — In infants a large portion of the rectum is situated in 
the abdominal cavity rather than in the pelvis. In infants and chil- 
dren it has three curves- — one lateral and two anteroposterior. The 
gut is nearly straight and occupies a more or less vertical position, 
hence the frequency of prolapse. The attachment of the rectum to 
the surrounding parts is not extended as high in children as in adults, 
hence the rectum is more liable to be pushed out. The rectum of the 
newborn infant may be divided into three parts. The first lies in 
front of the sacrum and ends at the lower end of the bone ; the second 
is short, and in this respect differs from the adult gut, being also more 
vertical ; the third portion is long, and extends downward, and some- 
what backward. The second portion being short, when the rectum 
is distended, the gut is straightened out and the whole rectum extends 
downward and backward (Symington). All these data are of impor- 
tance in applying methods of therapy (enteroclysis, etc.) to this organ. 

Prolapsus Ani. — Prolapsus ani is a condition frequently met with 
in infants and children. It may amount only to an eversion of the 
mucous membrane. There is in some cases a complete descent of 
part of the rectum, which protrudes from the anus to the length of 
one or two inches. 

Etiology. — The etiology of this condition is obscure. It evidently 
occurs only in cases in which' the pelvic attachments of the lower 
bowel are lax. It is favored by anatomical conditions elsewhere 
mentioned. It is seen in children who are constipated, in those who 
suffer from diarrhoea, and also in those whose movements are not 
normal. Any abnormal condition in the neighboring organs, such as 
the bladder and urethra (stone), may cause excessive straining and 
consequent prolapse of the gut. A rectal polypus may cause prolapse. 






DISEASES OF THE STOMACH AND INTESTINES. 553 

Symptoms. — In some cases the only symptom is the appearance of 
a small quantity of mucus and blood on the diaper with each move- 
ment; in these cases the prolapse returns spontaneously. In other 
cases the bowel descends to the extent of one or two inches with the 
movement, and remains prolapsed. If a polypus of the lower part 
of the rectum is the cause of the prolapse, it is seen protruding from 
the prolapsed portion. 

Treatment. — The first step is to replace the protruding gut. The 
gut is anointed with olive oil or vaseline and gently replaced with a 
towel. The movements are so regulated by diet and cathartics that 
the stools are passed without straining. Three times daily a supposi- 
tory containing grains ij to iij (0.12 to 0.2) of tannic acid is placed 
in the lower bowel. While the movements are being passed the pa- 
tient is kept in the recumbent posture on a bedpan. This treatment is 
frequently successful. In other cases, the buttocks are drawn together 
by adhesive straps and the child is allowed to pass movements thus 
strapped. Cocaine and strychnine are used both in suppositories and 
hypodermically. The protruding portion is painted with cocaine. 
These measures have their failures and successes. The only satis- 
factory method is that first advised — of a strict diet, the recumbent 
posture at stool, and the astringent suppository. The Paquelin 
cautery is sometimes employed to cauterize the mucous membrane. 
The danger in this method is the substitution of a traumatic stricture 
of the anus for the comparatively harmless prolapse. Application of 
the pure stick of silver nitrate to the anus twice a week, has given 
good results. If a polypus of the rectum is the cause of the prolapse, 
the growth should be removed by surgical means. 

Fissure of the Anus. — Fissure of the anus is seen in syphilitic 
infants, in those suffering from marked constipation, and in infants 
that have eczema of the anus. It may be the result of the repeated 
introduction of the hard nozzle of an enema syringe. The fissure 
may be so slight as to be only a line-like tearing of the mucous mem- 
brane, or may consist of a broad ulcer with a hard granulating base. 

Symptoms. — As a rule, the infants are constipated. When a 
movement is passed, the infant cries and there is great pain. A few 
drops of blood are passed on the diaper. 

Diagnosis. — The presence of a fissure of the anus sometimes 
escapes the notice of the physician. If there is a history of the above 
symptoms, the physician should place the infant on a table, grasp the 
buttocks with the palm of the hands and separate them forcibly with 
the thumb. The anus is thus everted, and if a fissure is present it 
will at once become apparent. 

Treatment. — A small fissure is sometimes very successfully treated 
by regulating the bowels. It is touched with a 10 per cent, solution 



j 



554 DISEASES OF THE STOMACH AND INTESTINES. 

of silver nitrate once a day. In the severe cases silver applications 
will not avail ; forcible dilatation of the rectum by means of the 
thumbs must be resorted to. This procedure not only cures the fissure, 
but is also an effectual remedy for the accompanying constipation. 

Spasm of the Anus. — Cases of nervous spasm of the sphincter 
ani occur in infants. The infant is constipated and cries at each 
movement. There is no bleeding, nor does examination reveal any 
fissure, but only marked contracture of the anal opening. In these 
cases it is almost impossible in an examination to bring down the 
upper part of the anal gut. 

The remedy is to regulate the bowels. If by this means success 
in overcoming the spasm is not attained, forcible dilatation is the 
only resource. 

Proctitis. — Apart from the membranous and catarrhal forms of 
proctitis, which occur with similar conditions of the intestine, the 
only form which is of interest is the gonorrheal. This occurs as a 
complication of vulvovaginal gonorrheal inflammation. In these 
cases the introduction of the gonococcus from the vagina into the gut 
has occurred through careless thermometry or the giving of enemata 
without previous cleansing of the parts. The disease is very painful 
and at the same time trying to the infant or child. With the dis- 
charge of pus from the anus there are tenesmus and a bloody discharge 
with the movements. The purulent discharge shows gonococci. 

Treatment. — The treatment consists in the injection of protargol 
solutions, 2 per cent., at a temperature of 105° to 108° F. (40.5° to 
42.5° C), into the rectum twice daily. The bowels are regulated. 
Suppositories of tannin or tannigen are also of value and give great 
relief; one containing grains iij (0.18) is given per rectum twice 
daily. In the later stages it may be necessary to paint the lower bowel 
with a very weak solution (0.5 per cent.) of silver nitrate. 

Polypus of the Rectum. — Polypus of the rectum is not rare in 
childhood, but is not often seen in infancy. It occurs most frequently 
from the third to the seventh year of life. The polypi are adenomata. 
I have examined several, and have found them to have the structure 
described by Baginsky. They may be single or multiple, usually 
have a pedicle, but may be attached to the wall of the gut by a broad 
base. As a rule they are situated on the posterior wall of the rectum 
seven or eight centimetres above the anal ring, but may be on the 
anterior wall. In most cases the polypi exist here only, but I have 
seen them higher up in the gut, and in one case in a child of five years 
from whom several rectal polypi had previously been removed, I 
diagnosed a number in the descending colon. In this case lapa- 
rotomy and incision of the gut proved the diagnosis to have been 
correct. The polypi may, if they become numerous, assume a malig- 



INTESTINAL PARASITES. 555 

nant character; this is especially true of the growths with a large, 
broad intestinal base. 

Symptoms. — The characteristic symptom is intermittent hemor- 
rhages from the gut, which may be profuse. At times the outer 
surface of the movements is streaked with blood, the bowels being 
constipated or normal, with an occasional mucous diarrhoea. If the 
polypus is low down, there is straining at stool with prolapsus of the 
gut. Many of the children thus affected are pale, have a pasty hue 
of the skin, and show evidences of lymphatism. 

Diagnosis. — Bleeding from the bowel, in the absence of other symp- 
toms, should at once suggest the necessity of digital exploration of 
the lower bowel. If a polypus is not found, a careful palpation of 
the abdomen made when the patient is fasting should be the next 
procedure. If the child is tractable and the abdomen soft, it may be 
possible in rare cases to feel a tumor the size of a hazelnut at one 
side of the umbilicus. 

Prognosis. — The prognosis is good ; removal of the polypi is rarely 
followed by recurrence of symptoms, even in cases in which they are 
situated in the descending colon. If they are removable and not very 
numerous, the patient recovers. 

Treatment. — If the polypus is low down and pedunculated, it may 
easily be snared with or without the aid of a rectal speculum, and 
crushed or ligated off. If it is high in the sigmoid flexure, the anus 
should be dilated and the growth reached by means of a speculum. 
In cases in which the growth is in the colon, laparotomy, enterotomy, 
and ligation are indicated. 

INTESTINAL PARASITES. 

The most common parasites found in infants and children are the 
K'ematoda, or round worms, and the Cestoda, or tapeworms. The 
round worm is smooth and light brown or reddish in color, the female 
being larger than the male. The eggs are found in the stools ; they 
are from 0.05 to 0.06 mm. in diameter and are surrounded by an albu- 
minous envelope. The worm is several inches long. Oxyuris vermi- 
cularis is about 1 cm. long, the male having a length of 4- mm. The 
eggs measure 0.05 mm. in their long diameter. 

The tapeworms in mature state consist of rectangular segments. 
The head and neck are called the scolex ; the segments, proglottides. 
The worms are hermaphrodites. The solium is sometimes several 
metres long. The head is of the size of a pin's head, with a pro- 
jecting proboscis armed with booklets. The eggs oi the solium are 
ovoidal, 0.3 mm. in diameter. The Taenia mediocanellata has ;i more 
cuboidal head withoul booklets (Fig, L13). 



556 



INTESTINAL PARASITES. 



Diagnosis. — There are no symptoms which can be traced to the 
presence of these worms in the gut. If they increase in enormous 
numbers, they may cause symptoms of mechanical obstruction. 
Without the presence of the eggs or links of the worm, a diagnosis 
is not possible. Their presence is made known by the passage per 
anus of the links of such worms as the tapeworm. Round worms 
may also pass out of the anus, or may be vomited if they gain access 
to the stomach. Thread worms may cause excessive pruritus, and 
may not be discovered external to the anus. In that case the faeces 
should be carefully examined for the eggs of the worms. 



Fig. 113. 

2 






OBEoaasp 



1. Oxyuris vermicularis, pin worm, natural size. 

2. Egg of Ascaris lumbricoides. 

3. Egg of Oxyuris vermicularis, pin worm. 

4. Egg of Taenia solium. 

5. Proglottides or links of Taenia solium. 

6. Proglottides of Bothriocephalus latus. 



Round Worms (Ascarides Lumbricoides). — This parasite is 
found in the small gut ; it may invade the stomach or may pass down- 
ward into the rectum. Cases are recorded (Borger) in which it has 
passed into the bile-duct and caused abscess of the liver. There may 
be only one or many of these worms in the gut. Leuckart states that 
they may form large masses in the gut, and thus cause intestinal 
obstruction. They have been known to perforate the gut and cause 
peritonitis. The eggs are introduced into the gut through the medium 
of drinking-water, fruit, and vegetables. Epstein cultivated the eggs 
outside of the body and then introduced them into the gut, where they 
developed. The male worm is 250 mm. long, the female being longer. 

Symptoms. — The symptoms caused when these parasites have once 
gained access to the body are not characteristic. I have seen the 
worms passed or vomited by children apparently in normal condition. 

Treatment. — The treatment consists in placing the patient on a 
milk diet. After a few days the following powder is administered 
two or three times daily : 



INTESTINAL PARASITES. 557 

Calomel, 

Santonin aa gr. £ (0.016). 

Santonin is sometimes administered in the form of pastiles, but is not 
more satisfactory than the above preparation. 

Oxyuris Vermicularis (Pin Worm; Thread Worm). — Brass 
showed that the habitat of these worms is the small intestine, whence 
they pass into the caecum. The female worm lays its ova in the folds 
of the gut. They may pass into the stomach and thence into the 
mouth, but more frequently pass out of the anus into the vagina or 
into the prepuce and urethra. They exist in enormous numbers in 
the gut, are exceedingly small, and have the appearance of fibres of 
cotton fabric. They can be seen by spreading the nates apart. 
They are then found in the anus, or in female children in the four- 
chette. The principal symptom is intolerable pruritus, so intense as 
to deprive the children of sleep. This worm is found only in the 
human subject. It is conveyed from person to person through un- 
cleanliness. The larvae adhere to the fingers, and thence are intro- 
duced into food-stuffs. 

Treatment. — It is a very difficult task to dislodge these worms; 
injections by the rectum cannot reach those higher in the intestine. 
The plan which I have followed, and which gives relief, is to give 
daily enemata of quassia wood before bedtime : 

Quassia wood (ground) ^j (31.0). 

Aquae dest Oj (500.0). 

Make an infusion and strain. 

I have in addition utilized the prescription of santonin and calomel 
given above for the round worms. 

Schmitz recommends the administration of naphthalin, grains j to 
iij (0.06 to 0.18), t. i. d., for a week, after which it is discontinued 
for a few days, and then given again. 

Tapeworm (Tcenia). — Taenia are quite common in children, and 
have been found in the newborn infant (Miiller and Armor). Nu- 
merous cases have been recorded of the presence of these worms in 
infants from the third to the twelfth month. They are most fre- 
quently found between the first and the third year. The varieties 
most commonly found in children are : Taenia solium, Taenia medio- 
canellata, Taenia elliptica, Bothriocephalus latus. 

Sources and Varieties. — Tamia Elliptica. — The lice of the house- 
dog and cat are introduced by the fingers of the children into their 
mouths, and thus gain access to the gut. There the larvse of the 
tapeworm which they contain develop. 

Tcenia Solium. — The larvae of this worm are found in badly 
cooked pork or beef. 

Tcenia Mediocanellata. — The larva of this worm arc found in 



558 INTESTINAL PAEASITES. 

beef. Bothriocephalus latus is introduced by the ingestion of infected 
fish-food. 

Tbe larva? of tapeworm may exist in the flesh of the hare, pigeon, 
pheasant, chicken, goose, or duck. Ice. if made from infected water, 
may be a means of introducing the larvae in the body. It is thus 
not necessarily the meat-eating children who run the danger of swal- 
lowing the larva? of tapeworm ; milk if diluted with infected water 
may contain them. 

Symptoms. — Tapeworms may exist for months or years in the 
body of a child without causing untoward symptoms. As many as 
three varieties of the worm have been found in the same child. The 
symptoms are not characteristic. The passage in the movements of 
the links of the taenia is the only positive evidence of their presence. 

Treatment. — The only successful treatment for the expulsion of 
the tapeworm is that which consists in the administration of filix 
mas in some form. It should be freshly prepared and given in 
liberal doses: Ext. a?th. filix mas, TT[xxx (2.0) to 5j or 5ij (4.0 or 
8.0), is made into an emulsion with gum tragacanth, and mixed with 
equal parts of castor oil. The administration of this mixture is pre- 
ceded by a day or "more of milk diet. The child is then given from 
half a drachm to a drachm (2.0 to 4.0) of the filix mas with castor 
oil in divided doses*. The recumbent posture is maintained in case 
nausea should be experienced. The movements containing the worm 
are carefully washed through a sieve, and the smallest part of the 
worm sought for in order to see if the head has come away. 

The patient should be given a drawing of the comparative size of 
the head and links of the worm, in order that the head may not be 
lost, or the physician may seek it himself. 

Uncinariasis or Hook-worm Disease. — This disease is widely 
prevalent in the South, where some two million men, women and chil- 
dren are said to be affected. The children are the principal victims. 

Etiology. — This disease was brought to America by the negro, 
whose habits lead to infection of the soil and spread of the disease to 
the white man. The hook-worm was known to the Egyptians. In 
Europe it was discovered in the badger by Goeze in 1782 and was 
named by Froelich hook-worm. It was long recognized in the South, 
but Stiles isolated a distinct American species of Anchylostoma duo- 
denale, the European worm, in 1902. 

Since then the literature is rich in clinical descriptions of the 
affection now called hook-worm disease. Adams described some cases 
in children. The hook-worm, or Uncinaria americana, is so called 
because in the American variety the head turns backward, forming 
a hook, while in the European variety the Anchylostoma duodenale, 
the mouth contains four hood-like processes by means of which the 



INTESTINAL PARASITES. 5o9 

parasite fastens itself to the intestine (Fig. 114; . The worm is half 
an inch long, its habitat is the intestine, it sucks blood and at the same 
time injects into the circulation a toxin. The parasite produces 
which may be hatched outside of the intestine in about 24 hours, pro- 
ducing larvse. The infection is carried by the hands and drinking 
water. It is found in the soil of the sandy southern districts. It 
may enter the body, as established by Loos, through the skin. Enter- 
ing the hair-follicles, it gains admission into the circulation, then into 
the lungs and oesophagus and into the stomach. 

Symptoms. — The symptoms consist in a progressive anaemia; the 
hemoglobin in Adams's case was reduced to 20 per cent. The skin 
is dark, waxy and hydrsemic, the face is bloated, the abdomen pro- 

Fig. 114. 




American hook-worm larvae, eggs. Small figure shows actual size. 



tuber ant and emaciation results, with a tendency to skin ulceration. 
The tongue is brown and spotted and the mucous membranes pale. 
The temperature may be Subnormal or there is occasional fever. The 
muscular weakness is extreme and mental apathy and stupidity are 
characteristic. There is headache, dizziness, epigastric pain and a 
craving for peculiar articles of diet. Nearly all of the victims of the 
affection are dirt-eaters. There may be constipation or diarrhoea. 
The blood shows diminution of white blood-cells and eosinophilia. 

Diagnosis. — The diagnosis is made from an examination of the 
fasces in which the eggs of the parasite are found. Stiles describes 
the eggs, which are 60 to 70 /x in length and 41 to 4l> ^ in width. The 
larvae may be developed from them artificially. The disease may 
last for years if not eradicated by treatment. Neglected cases cannot 
be cured. 

Treatment. — Treatment is the administration of thymol suggested 
by Bozzolo. There must be an abstinence during treatment from 
alcohol or fatty substances which dissolve the thymol. Adams gave 
his patient, a boy of twelve, 80 grains, in doses of 10 grains every 



560 DISEASES OF THE LIVEB. 

hour and a half, followed by Epsom salts. After a time the fasces 
are examined. If the ova are still present, the treatment is repeated. 
Good food and tonics aid restitution. 

DISEASES OF THE LIVER. 

Anatomical. — The weight of the liver in infants and children is 
from one-twentieth to one-thirtieth of the body weight ; in the adult 
it is one-fortieth. 

Weight. — Birch-Hirschfeld gives the following weights of the 
liver : 

Birth 127 5 years 480 

6 months 197 10 years 830 

1 year 312 Adult 1627 

2 years 346 

Examination. — The liver is examined with the patient in the 
recumbent or semirecumbent posture. The physician may palpate 
for the liver or mark out the organ more accurately by percussion. 
In marking out the organ, the upper limit, the lower edge, and the 
area of superficial dulness are determined. Perfect accuracy by deep 
percussion is not feasible, because in order to obtain absolute dulness 
some force must be used, and vibratory echoes of other neighboring 
organs — the lungs and intestines — are thus caused. In all cases it 
it well to determine the upper limit of dulness at a point where the 
liver comes in contact with the chest-wall. 

The lower border of the liver is determined by palpation and per- 
cussion. The lower border projects normally in infants and children 
below the border of the ribs. In the right mamillary line this pro- 
jection may vary from 1 to 2.5 cm. At the xiphoid appendix the 
liver may project to the extent of 2 to 6 cm. and still be within the 
normal limits. These conditions may exist up to the tenth year. 
The exact age at which the liver assumes the adult dimensions has 
not been determined. In some adults, however, the projection below 
the border of the ribs is the same as in children. Since the size of 
the liver varies, caution should be exercised in pronouncing the organ 
enlarged. The gut, ascites, and tympanitic distention may obscure 
the lower limit of the liver both to palpation and percussion. 

Palpation. — By palpation, the location of the lower border of the 
liver may be determined, and whether it is rounded or sharp, also, 
if the liver be enlarged, the character of the projecting portion, whether 
smooth or even. In infants and children the region of the gall-bladder 
is palpated, but it is difficult to determine in these subjects whether 
this organ is enlarged or absent. Henoch and Murchison have re- 
corded fatal cases of increasing and persistent icterus in which there 
was congenital absence of the gall-bladder. 



DISEASES OE TEE LIVE It. 561 

Percussion. — Percussion should be performed in the mid-line from 
the base of the xiphoid cartilage downward, in the right mammillary 
line from above downward, and sometimes in the mid-axillary line. 
In order to determine accurately the superficial dulness, the whole 
extent of the dulness should be measured. This is rarely necessary 
except in investigations for scientific purposes. In cases of effusion 
into the pleural cavity, the upper limit of dulness is continuous with 
the dulness or flatness of the fluid. The displacement below the 
border of the ribs only can then be determined. In rare cases of sub- 

Fig. 115. 




Method of palpating the projection of the liver below the ribs. 

phrenic abscess there is an extension of the upper limit of dulness into 
the limits of the chest cavity, and displacement of the lower border 
of the liver downward. Steffen gives the following measurements of 
the superficial liver dulness in the median and mammillary lines : 

Midline. Mammillary line. 

At birth 3.5 cm. 2 cm. 

At one month 5 " 5 " 

At six months 4.5 " 4.5 " 

At one year 4.5 " 4 " 

At two years 5.2 " 5 " 

At five years 5 " 6.5 " 

At ten years 5 " 6 " 

These measurements also vary greatly, especially in infants under 
one year of age. 

Tumors and Conditions Simulating Enlargement or Disease of 
the Liver. — The following tumors and conditions simulate enlarge- 
ment or disease of the liver: normal rotation of the liver: phantom 
tumor; circumscribed empyema, or pleuritic effusion; subphrenic 
abscess; circumscribed peritoneal effusion between the liver and dia- 
phragm ; tumors or cysts of the right kidney. 

Normal Rotation of the Liver. — In infants below two years of age 
the liver may have a lax suspensory ligament. In such cases the 

36 



502 DISEASES OF TEE LIVES. 

liver will rotate and be found for a varying distance below the free 
border of the ribs, depending much on the amount of distention of 
the intestine. When the latter is not distended the liver will rise up 
beneath the free border of the ribs. 

Phantom Tumor. — Phantom tumor is described by Murchison. It 
is a soft or hard epigastric tumor, which may project downward as 
far as the umbilicus. Whether it is dull with a tympanitic note, or 
tympanitic, depends on the amount of muscular contraction. There 
is no fluctuation or flatness. The tnmor is present when the patient 
is standing or in the recumbent position. It disappears under anaes- 
thesia. A tumor of this kind should not be punctured until it has 
been observed under anaesthesia, since there is danger of puncturing 
the intestine and causing peritonitis. 

Empyema. — In simple or encapsulated empyema on the right side, 
the liver is displaced downward. The upper dulness extends into 
the pleural cavity; the lower part of the thorax may enlarge to such 
an extent as to press the ribs apart and cause fluctuation between 
them. There will be dulness or flatness in front or behind over the 
lower part of the pleural space, and perhaps disappearance of the 
respiratory murmur. It should not be forgotten that there is always 
a possibility of the presence of subphrenic abscess, or of abscess in 
the upper part or on the surface of the liver, bulging into the pleural 
cavity. In that case there will not only be bulging of the lower ribs, 
but also a continuation of dulness for a variable distance upward. 
The liver may be enlarged downward or not at all. If the tumor is 
beneath the diaphragm and displaces the liver downward, the respira- 
tory murmur may be heard to the normal, or almost normal, limit, 
and yet dulness due to the upward projection of the tumor may be 
present. 

Kidney Tumor. — Kidney tumor may extend from behind, beneath 
the liver, and simulate liver tumor. In such cases, the lumbar flat- 
ness extending below the border of the ribs will be a guide. 

Enlargements of the Liver. — Enlargements of the liver in infancy 
and childhood present much the same physical signs as in the adult, 
but there are some states which are peculiar to early life. 

Anaemia Infantum Pseudoleukaemica of von Jaksch. — Anaemia in- 
fantum pseudoleukaemica of von Jaksch causes great enlargement of 
the liver and spleen. The lower edge of the liver is rounded; the 
lymph-nodes are enlarged, and the blood presents certain features 
characteristic of this anaemia. 

Simple Rachitis. — Simple rachitis causes slight or marked enlarge- 
ment of the liver, as well as real enlargement of the spleen. In some 
cases, the liver is not really enlarged, but may be displaced downward 



DISEASES OF THE LIVEE. 563 

"by the deformity of the thorax. Simple icterus usually causes en- 
largement of the liver, which retrogrades after a few weeks. 

Still's Rheumatoid Arthritis. — In Still's rheumatoid arthritis there 
is considerable enlargement of the liver. 

Congenital Syphilis. — Congenital syphilis may cause slight en- 
largement of the liver which, up to the end of the second year, is 
present without icterus. The liver is enlarged in cirrhosis abscess, 
and fatty degeneration of the organ. It is greatly enlarged in acute 
and chronic leukaemia. 

Jaundice (Catarrhal Icterus; Catarrhal Jaundice; Infectious 
Icterus). — Simple jaundice is a common disease of infancy and child- 
hood. In its simplest form, it was formerly believed to be due to an 
obstruction of the common bile-duct with mucus. In recent years, 
the French clinicians have described a form of jaundice which they 
regarded as infectious. The first cases of the kind were published 
in 1881 by Weiss, ChaufTard, and Landouzy, in France, and by Weil, 
in Germany. There is at present a tendency to regard all cases of 
jaundice in infants and children, not due to mechanical obstruction 
of the duct or disease of the liver, as infectious (Botkin, Hennig, 
Barthez, Henoch, and others). Thus simple icterus would be re- 
garded as a mild form of infectious icterus. This view has recently 
been elaborated by Kissel. The theory that errors of diet cause a 
catarrh of the gut, extending into the duct and thus obstructing it, 
finds little support. On the other hand, the theory of the infectious 
nature of even the mildest cases of jaundice is supported by the fact 
that these cases occur in groups and epidemics. 

Morbid Anatomy. — In cases of fatal icterus, there are found 
atrophy and fatty degeneration of the liver cells. The interstitial 
tissue around the portal vein is infiltrated with small round cells. 
There is parenchymatous degeneration of the kidney. The whole 
picture resembles that of acute yellow atrophy. The mild cases of 
icterus have not yet been studied. 

Bacteriology.. — The bacteriology of the various forms of icterus 
remains to be studied. In one case Jager found a bacillus of the 
proteus group in the urine. 

Occurrence. — The disease may appear at any period of infancy 
and childhood. It is most common between the second and fifth years. 

At present, all primary forms of jaundice may be clinically clas- 
sified as follows: The very mild forms (catarrhal icterus) : the severer 
forms; the fatal forms. It is highly probable that all are infectious 
in origin. The secondary forms of jaundice are not considered in 
this section. 

Symptoms. — In the mildesl forms there are no symptoms at the 
onset. In some mild cases there are vomiting, constipation or symp- 



564 DISEASES OF THE LIVEE. 

toms of intestinal indigestion and fetor of the breath, and the tongue 
is coated. The skin assumes a saffron line and the conjunctiva? are 
distinctly yellow. The appetite is capricious ; the urine is brownish 
and contains bile-pigment. The movements are like clay, and may 
have a bad odor. There is pruritus of the surface. The child may 
be somewhat depressed. In the very mild forms there is no febrile 
movement. In the majority of cases, there is rapidity of pulse and, 
in some cases, irregularity. In the severer forms the symptoms are 
more marked. The vomiting recurs at intervals, the intensity of the 
jaundice is much the same as in the mild forms, and the temperature 
may in the course of the disease be raised a degree or more. The 
attack may be ushered in by a chill. There is some prostration and, 
in a few cases, diarrhoea. The fatal cases, which were first described 
by Weiss and the French school, are severer forms of infection. The 
symptoms of cholsemia are much more marked. There are delirium, 
unconsciousness, and cerebral symptoms. The pulse is greatly in- 
creased and the respirations are irregular. The patients die in an 
asthenic state. 

The liver is enlarged in even the mildest forms. In a recent 
series of 20 cases of mild icterus, I found the liver enlarged from 
four to seven centimetres below the border of the ribs, in the mam- 
millary line. The spleen was enlarged in most cases. The fact that 
in the mildest forms there is enlargement of the spleen lends support 
to the infectious theory of the disease. In the majority of my cases, 
the liver remained enlarged long after the icterus had disappeared. 
Kissel also found this to be the case. In some cases, three months 
elapsed before the liver returned to the normal limits. 

Duration. — The disease, even in the mild form, lasts from two to 
three weeks. The fatal forms may run their course much more 
rapidly. 

Treatment. — The treatment of icterus is very simple. An initial 
dose of calomel is given and the bowels are well evacuated. The 
patient is put on a milk diet, and is given a daily enema of water at 
a temperature of 85° F. (29.4° C). On every second day a small 
dose of calomel, grain J (0.03), is given to aid the enemata. Fresh 
air and daily alkaline baths are beneficial. Alkaline baths are made 
by adding a few tablespoonfuls of sodium carbonate and an equal 
quantity of salt to the water. 

Congenital Obstruction of the Bile-ducts. — Etiology. — The etiol- 
ogy of this affection is obscure. Some 70 cases of this condition were 
recently collected by Morse from the literature. The infants may be 
apparently normal at birth. 

Symptoms. — Intense jaundice is the first symptom noticed at birth, 
or on the second to the fourth day after birth. Meconium is first 



DISEASES OF TEE LIVER. 565 

passed by the infant, and then the stools are clay colored. The urine 
contains biliary coloring-matter. The liver is enlarged, as is also 
the spleen. Hemorrhages from the stomach and intestine and into 
the skin occur in time. Death occurs early, or in from three to eight 
months. In one of my cases three months of age, laparotomy showed 
the gall-bladder to be empty and shrunken. The liver was enlarged. 
There was an absence of the ducts leading to the gall-bladder. The 
stools were formed, white like curd of milk, stained only slightly as 
the tissues with bile. There were extensive subcutaneous hemorrhages. 

Morbid Anatomy. — Some portion of the bile-ducts may be oblit- 
erated and replaced by connective tissue. In other cases the walls 
of the ducts are simply swollen. The liver is enlarged and the seat 
of cirrhotic changes. 

Cirrhosis of the Liver. — This disease is rare in infancy and 
childhood. Of 62 cases collected from the literature by v. Kahlden, 
5 occurred in the newborn, 12 in the first two years of life, and 28 
from the ninth to the thirteenth year. It is more prevalent in the 
male sex. Of those cases in which the size of the liver was recorded 
19 were atrophic, 15 hypertrophic, and 6 normal in size. 

Etiology. — Demme has published 2 cases in children addicted to 
the use of alcohol. The influence of heart disease and the infectious 
diseases, such as scarlet fever and measles, in causing cirrhosis of the 
liver is not as yet understood. Cirrhosis of the liver occurs in forms 
of peritoneal tuberculosis and in syphilis. 

Morbid Anatomy. — The morbid anatomy of the affection is the 
same as in the adult. 

Symptoms. — The symptoms, which are the same as in the adult, 
include enlargement of the liver and spleen, icterus, and ascites. The 
icterus is, as in the adult, constant. 

The liver is not always enlarged, and in the cases in which it is 
of normal size the difficulties of diagnosis are increased. The spleen 
is most constantly enlarged. 

The recorded cases of cirrhosis following or complicating the 
exanthemata and diphtheria gave no previous symptoms. 

Fatty Degeneration of the Liver. — Fatty degeneration of the 
liver, with or without enlargement of the organ, occurs in forms of 
subacute and chronic constitutional dyscrasia. I have seen this dis- 
ease in infants who died with tuberculosis, chronic or subacute intes- 
tinal diarrhoea, rachitis, Henoch's purpura, or acute leukaemia. I 
have also seen it in cases of phosphorus-poisoning. The symptoms 
and signs do not differ from these seen in the adult. The diagnosis 
can hardly be made tin ring life. 

Syphilis of the Liver.- Enlargemenl of the liver is common in 
syphilis of infants and children. The spleen may also be enlarged. 



566 DISEASES OF THE LIVEE. 

There may be icterus. There may be other symptoms of syphilis, 
but none which can be traced to enlargement of the liver. 

There are four histological forms of this variety of hepatic en- 
largement : 

a. The form in which gummata are found in the liver. This is 
rare. I saw a case in an infant sixteen months of age in which there 
were also gummata of the cranial and the long bones. 

b. The diffusely cirrhotic liver. In this form the connective 
tissue is quite evenly distributed throughout the liver. 

c. The lobulated liver, in which the connective tissue divides the 
organ into sections. I have seen a case in a girl eight years of age. 

d. The so-called miliary syphilis of the liver, in which the organ 
is strewn with miliary collections of round cells closely resembling 
miliary tubercle. The nodules are situated in the interstitial con- 
nective tissue. They rapidly undergo fatty degeneration. 

Clinically the cases which I have met were mostly those in which 
the liver, hard and nodular, could be felt below the border of the 
ribs. In one case there was a history of syphilitic accidents, in 
another old cicatrices existed on the lips and face. In a third, case 
the patient had Hutchinson teeth; the liver and spleen were both 
enlarged and nodular. 

Abscess of the Liver (Suppurative Hepatitis). — Etiology. — This 
disease occurs in the newborn as a form of sepsis. Otherwise its 
etiology in infancy and childhood is identical with that in the adult. 
It may follow a traumatism or complicate appendicitis (septic), it 
may occur in peritonitis with pyelophlebitis, or it may follow the 
infectious diseases, or dysentery. In the literature rare cases are 
described, in which Ascarides lumbricoides have caused abscess of 
the liver in children, by migrating into the gall-bladder through the 
common duct. 

The occurrence of this disease, though not rare in tropical coun- 
tries, is less frequent in districts in which dysentery is not endemic. 
It may occur as early as the fifth month of infancy (Oliveira). The 
left lobe of the liver is most frequently involved. The Amoeba coli 
is not always the cause, being an etiological factor in 20 per cent, of 
the cases. 

Symptoms. — The symptoms in these cases are first those of dysen- 
tery; then, after improvement sets in, the symptoms of abscess, with 
fever, swelling of the abdomen, and enlargement of the liver upon 
palpation appear. The liver may enlarge as much as 10 cm. below 
the tip of the ensiform cartilage. 

Course. — The abscess may perforate into the intestine, pleura, or 
peritoneum. If it perforate into the intestine recovery results. Any 
other termination is disastrous. 



DISEASES OF THE PERITONEUM. -067 

Treatment. — The treatment of abscess of the liver in children is 
much the same as in the adult. If operated early the prognosis 
is good. 

Acute Yellow Atrophy of the Liver. — The disease is extremely 
rare in infancy and childhood. Lanz published a case in a boy four 
years of age. In that there was no splenic tumor or hemorrhages, it 
differed from the picture in adult cases. The cases in the literature 
are as follows : Pollitzer, infant, one month of age ; Senator, infant, 
eight months; Mann, infant, ten months; Greves, infant, twenty 
months ; Widerhofer, child, one and three-fourths years ; Rehn, child, 
two and one-half years; Loschner, child, three and one-half years; 
Mettenhemier, child, four years; West, child, six years; Merkel, 
child, six and one-half years ; Rosenheim, child, ten years ; Steiner, 
child, ten years ; Folwarczny, child, fourteen years. 

I have seen only one case of atrophic liver. The patient, a boy 
of eleven years of age, with very small kidneys, had nephritis which 
had appeared six years after an attack of scarlet fever. The liver 
dulness became gradually smaller from the time of admission to the 
hospital until death. At autopsy, the liver was found to have one- 
half the normal weight and to be the seat of marked parenchymatous 
degeneration. 

Tumors of the Liver. — Tumors of the liver in infancy and child- 
hood may be benign or malignant. 

The benign are cavernous tumors or cystic degenerations of the 
liver. 

The malignant tumors are the carcinomata or adeno-carcinomata 
and more rarely sarcomata. StefTen collected 39 cases of primary 
malignant growths of the liver occurring mostly in the newborn. 

Stoos observed an adeno-carcinoma in a child five years of age. 

Parasites of the Liver. — These are exceedingly rare and are 
classified by Stoos as Distoma hepaticum, Ascarides, Echinoeoccus. 
Cystocerci, and Pantastomum denticulatum. 

Biliary Calculi. — Still has collected 8 cases ranging from 2 to 14 
years of age. I have had two cases in older children. Lillienthal 
has operated in several cases, one a boy of five years of age. 

The symptoms are similar to those in the adult. Still's eases 
were mostly in the newborn, the main symptom being intense per- 
sistent icterus. On autopsy multiple calculi were found in the 
biliary ducts. 

DISEASES OF THE PERITONEUM. 

Ascites. — Ascites is a serous effusion into the peritoneal sac, and, 
as in the adult subject! it is generally secondary either to some disease 



568 DISEASES OF THE PEKITONEUM. 

of the peritoneum, such as tuberculosis, or chronic disease of the 
heart, liver, or kidneys. It may also be due to some obstruction of 
the portal circulation, caused by enlarged glands or tumors of the 
peritoneum. Ordinary ascites has the same characteristics in the 
infant and child as in the adult, and is recognized by the same phys- 
ical signs. It is therefore superfluous to go into details in this place 
as to the physical characteristics of the fluid accumulation in the peri- 
toneal cavity of infants or children. 

Some rare forms of ascites may be congenital. In diagnosing 
ascites in infants and children, we must be careful not to confound 
it with local accumulations of fluid due to cysts or tumors in the peri- 
toneal cavity. Cysts, or cystic tumors, have local circumscribed 
physical characteristics, and with care they cannot be mistaken for 
ascites. There is a form of ascites which occurs rarely in children, 
and of which I have seen one example in a boy six years of age. It 
is called chylous ascites, and is marked by its chronicity and the 
milky or fatty nature of the exudate. It is more frequent in adults ; 
but when present in infants or children, it is found between the ages 
of seven and ten years. In one case recorded by Wicklen, the accu- 
mulation followed an attack of pertussis in an infant six months of 
age. In a case recently reported by Kerr the ascites disappeared 
after abdominal tap. There was a history of syphilis. 

The etiology of chylous ascites is obscure, although in some cases 
tuberculosis of the peritoneum has been found postmortem. It has 
followed traumatism, eruptive fevers, or an infection with filaria. 
The symptoms are those of ascites, and it is not until the withdrawal 
of the fluid that the true nature of the affection is discovered. The 
fluid withdrawn has a milky, opalescent appearance, and is of two 
forms, in one of which there is a fine emulsion of fat-globules with 
red and white blood-cells ; the other form contains no such element, 
but is chylous in color. At autopsy various lesions have been found, 
as stated, including tuberculosis, syphilis of the liver, cirrhosis of the 
liver, an enlarged spleen, with lesions of the thoracic duct. In some 
cases there has been tuberculosis of the thoracic duct, or this combined 
with tuberculous disease of the lymph-nodes, with apparent obstruc- 
tion of the lymph-vessels. 

Treatment. — The treatment of ascites in children is carried out 
along the same lines as in the adult patient. 

Acute Peritonitis. — Acute peritonitis may be general or local, 
and is due to an infection of the peritoneum. 

Etiology. — According to Tavel, Lanz, and Treves, the disease is 
caused by various bacteria, such as streptococci, staphylococci, pneu- 
mococci, or coli bacteria, but the most active role, even in the traumatic 
and perforative forms, is played by the Bacterium coli communis. 



DISEASES OF TEE PERITONEUM. 569 

Krogius examined 40 cases of perforative peritonitis following appen- 
dicitis, in 20 of which he found two or three species of bacteria; in 
only 7 cases did he find Bacterium coli alone. The species found 
were generally coli bacteria in combination with diplococci, pneumo- 
cocci, Diplococcus intestinalis, streptococci, coli gracilis. The re- 
maining cases contained the Streptococcus pyogenes, pyocyaneus, and 
Proteus vulgaris. The coli, however, was the most frequent micro- 
organism found. It is to be remarked that in 21 cases the Diplo- 
coccus pneumoniae was found combined with the Bacterium coli. 
This form must not be confounded with the cases in which the pneu- 
mococcus is found as the causative agent of peritonitis, especially in 
children (Netter, Sevestre, and others). 

We may have: (1) Acute tuberculous peritonitis. (2) Perfora- 
tive peritonitis, due to traumatism or some pathological perforation 
of the viscera or the serous coat of the intestine as a result of tuber- 
culosis, typhoid fever, dysentery, perforating ulcer of the stomach or 
duodenum, abscess of the liver, cyst of the liver, kidney, or spleen, 
rupture of the gall-bladder, strangulated hernia, intestinal intussus- 
ception, appendicitis, perforating lumbricoides — all these can be 
accompanied by the escape of gas, fsecal matter, bile, or blood into 
the peritoneal cavity. (3) Peritonitis may take place by extension, 
as is observed in cases where inflammation extends from a viscus 
without perforations. (4) Peritonitis may occur as the result of 
traumatism, as a blow or fall or an operation. (5) Pneumococci 
may cause an acute primary peritonitis, or may give rise to the affec- 
tion by extension from the pleura or lung. (6) There is a gonor- 
rhoeal form of peritonitis. (7) Peritonitis may occur in the foetus 
or in the newborn. The latter has been described by Billard as fol- 
lowing intra-uterine infection, as a result of maternal disease ; or in 
the newborn peritonitis may be caused by streptococcal infection of 
the umbilicus, and extension from this point to the peritoneum. 

Symptoms. — The symptoms of acute peritonitis at the onset may 
be insidious. Such forms occur in cachectic, marantic infants, or 
children; or the onset may be acute and sudden, as in the primary 
form. 

Pain may be localized either in the iliae fossa or around the umbil- 
icus, spreading thence over the whole abdomen. The child lies quietly 
on the back, with superficial respiratory movement. There is, as in 
the adult subject, meteorism or tympanites. There is vomiting, first 
of the contents of the stomach, then the vomit us becomes green or 
biliary. It may subside a Tier two or three days. There may bo a 
diarrhoea, but in most cases there is constipation as obstinate as in 
intestinal obstruction. The tongue is moist, then dry; the buccal 
mucous membrane may be covered with sprue: the urine may be sup- 



570 DISEASES OF THE PEEITONEUM. 

pressed, and, as in the adult, there may be facies. The pulse ranges 
from 120 to 150, small and thready. The fever varies in extent, 
depending very much on the acuity of the infection. In perforative 
peritonitis there will be a sharp rise of temperature. 

Physical Signs. — The physical signs are much the same as are 
found in the adult. There is tympanites, the abdomen is distended, 
there is a disappearance of the liver dulness. In localized peritonitis 
there is local pain ; in general peritonitis the pain is general. If the 
peritonitis becomes general, there is, as a rule, an accumulation of 
fluid in the peritoneal cavity, and this may be made out by dulness 
in the flanks. As a rule, an examination of the blood will reveal an 
increased number of leucocytes or so-called leucocytosis, especially in 
the perforative forms. This latter sign is not of much value unless 
a previous leucocyte-count has been made or the case has been under 
constant observation, such as in forms of perforation occurring in 
typhoid fever, for even in these cases the increase in the number of 
the leucocytes is only comparative. Thus the leucocyte-count in the 
course of typhoid fever may be 6000 to 8000 ; whereas after perfora- 
tion the leucocytes may not increase beyond 10,000 to 12,000. In 
other words, they may simply reach the normal limit. 

Course and Termination. — Acute peritonitis, as in the adult, may 
remain localized or may spread and become general. In the latter 
case the prognosis is very grave. If local the exudate may become 
encysted, or, if general and left to itself, may result fatally, or the 
exudate in the peritoneal cavity may rupture in the vicinity of the 
umbilicus or through the vagina or rectum. Foudroyant cases last 
two or three days and result in death. This is especially so of the 
newborn. 

Complications. — Among the complications of acute peritonitis, 
either general or localized, are pleurisy, pericarditis, meningitis, 
pyaemia. 

Prognosis. — As stated, the general perforative forms present the 
gravest prognosis. Peritonitis of the newborn is fatal. 

Differential Diagnosis. — Peritonitis, acute, localized, or diffuse, must 
be differentiated from typhoid fever. In the latter disease there is 
sometimes a severe inflammation in the vicinity of the vermiform 
appendix, and in such cases we should be very careful that a perfora- 
tion has not escaped our notice. 

Colprostasis, or intestinal invagination, and gastro-enteric infec- 
tion may be mistaken for appendicitis, especially in young children, 
if the meteorism is great. 

Gonococcal Peritonitis. — Gonococcal peritonitis results from an 
infection of the peritoneal cavity by the Gonococcus of Neisser. 
Comby records 7 cases of gonococcal peritonitis. Hunner and Harris 



DISEASES OF THE PERITONEUM. 571 

record 7 cases. I have seen 2 cases. The infection takes place by 
way of the uterus and Fallopian tubes in the majority of cases. 

Etiology. — The gonococcus is the etiological factor in these cases, 
and the majority of recorded cases in children have occurred in young 
infants and children suffering from vulvovaginitis of a gonorrhoeal 
nature. In my two cases this was the etiological factor. The symp- 
toms are sudden pain, vomiting, fever ; or in other cases there results 
in the course of the vaginitis severe pelvic pain. In some cases the 
pain and fever are of short duration, and it must be surmise^d in these 
cases that the inflammation remains well localized to the pelvis. I 
have seen quite a number of these cases complicating vaginitis in 
young girls. 

The French have given the name of peritonism to these cases, 
thereby wishing to indicate their benign nature. The symptoms are 
so slight that one can scarcely believe that inflammatory reaction is 
present. Baginsky has published a case of general peritonitis resulting 
from gonorrhoea of the tubes, with an abscess-formation in Douglas's 
pouch. The gonococcus of this form of peritonitis may be associated 
with other bacteria, such as the staphylococcus. There are several 
forms of gonorrhoeal peritonitis : the general acute form, ending in 
death; the benign pelvic form, with subumbilical pain, and a third 
form occurring as a pelviperitonitis with adhesions and salpingitis. 
Diagnosis must be made from appendicitis, for which it may be mis- 
taken. Given a case of gonorrhoeal infection of the genitals in chil- 
dren, with sudden abdominal pain, fever, and general abdominal 
distention, the diagnosis presents no difficulties. 

Prognosis. — The French writers insist that the prognosis of gon- 
orrhoeal peritonitis is benign. On the other hand, such a prognosis 
will depend very much on the severity of the infection. Inasmuch 
as I have personally seen three fatal cases found at autopsy to have 
been due to gonorrhoeal peritonitis complicating vulvovaginitis, I can- 
not regard the general form of gonorrhoeal peritonitis as anything but 
a grave infection particularly fatal to children. 

Treatment. — The treatment of gonorrhoeal peritonitis varies ac- 
cording to the extent of the infection. If the peritonitis is localized 
to the pelvis it is quite evident that the treatment should be mostly on 
the lines laid down for the adult subject. If the peritonitis becomes 
general there will be a difference of opinion as to whether surgical 
interference is necessary. It is not within the scope of this work to 
discuss this aspect of the subject; but in a resume of the subject by 
Ilunner and Harris the surgical interference in gonorrhoea] perito- 
nitis is rather discouraged. In genera] peritonitis ot gonorrhoea] 
nature rest in bed, hot turpentine-stupes alternating every hour with 



572 DISEASES OF THE PEKITONEUH. 

warm stupes, mild catharsis, liquid diet, hydrotherapy, and general 
medical treatment are rather to be advocated. 

Pneumococcal Peritonitis. — Pneumococcal peritonitis, as has 
been stated, may be primary, and as such occurs most frequently from 
the second to the twelfth year of life. It may be secondary to pul- 
monary disease, such as pneumonia or pleurisy ; or may be primary, 
resulting from an infection of the peritoneum either through the blood 
or the genitals. The frequency of encapsulation of the pus around 
the umbilicus makes the genital way of infection very probable. 

Symptoms.- — The course of the symptoms in this disease recalls 
that of a pneumonia, by its sudden onset in subjects previously in 
good health. There is a chill, followed by fever, pain, vomiting, and 
some diarrhoea. After a period of eight days there is a deferves- 
cence of the fever and abatement of the symptoms. The abdomen, 
which has been previously distended and generally painful, with all 
the physical signs found in other forms of peritonitis, remains large 
and distended, pus accumulates, the umbilicus becomes prominent, 
and in this way we have a picture resembling ascites or tuberculosis 
of the peritoneum. I have seen a case in which the latter diagnosis 
was made. Pus may break spontaneously at the umbilicus or per- 
forate through the vagina. The disease is more frequent in girls 
than in boys, and, as has been stated, the pus has a tendency to be- 
come encysted and discharge at the umbilicus. The pus is of a 
creamy, yellow color, without odor. 

Michant has collected 33 cases of pneumococcal peritonitis occur- 
ring in children: 27 of these were girls; 22 were encysted, 11 were 
generalized. In 27 cases the disease was primary. 

Diagnosis. — This form of peritonitis is naturally mistaken for 
peritonitis following appendicitis. It may be distinguished from the 
latter, however, by its benign course. The pus, if it becomes encysted, 
may distend the abdomen to an enormous extent. I have seen a case 
in which the distention of the abdomen was enormous, resulting in 
the obstruction of the portal circulation, with dilatation of the super- 
ficial abdominal veins. There was perforation at the umbilicus, and 
a discharge of several pints of pus, followed by recovery of the patient. 
Appendicitis is more acute in its nature and does not extend over such 
a long period of time, with the benign result, as seen in this form of 
peritonitis. 

Tuberculosis of the peritoneum can hardly be mistaken for this 
form of peritonitis. Given a distention of the abdomen by a fluid 
pointing at the umbilicus, which fluid is found to be pus, we may 
surmise that there is a pneumococcal peritonitis. A positive diag- 
nosis can only be made by bacterial examination of the pus. 

Prognosis. — The prognosis, as a rule, is good, for in most of the 



DISEASES OF THE PERITONEUM. 573 

cases, the pus being encysted, the general peritoneal cavity remains 
free of infection. In the general form, however, the prognosis is 
more grave. Of 11 cases of this form 9 died of sepsis. 

Simple Chronic Peritonitis. — Although Henoch and Midler have 
reported cases of chronic idiopathic non-tuberculous peritonitis, its 
occurrence is still a matter of dispute. Nothnagel, linger, and 
Heubner, while not denying in toto its possible occurrence, insist on 
its extreme rarity. The absence in these cases of progressive emacia- 
tion is no proof of the non-tuberculous nature of the affection. The 
absence of the tubercle bacillus in the abdominal exudate is of slight 
diagnostic value. In 29 cases of undoubted tuberculosis of the peri- 
toneum Herzfeld found the bacillus only once in the ascitic fluid. In 
some forms of tuberculous peritonitis the nutrition may not only be 
good, but there may be no history of tuberculosis or scrofulosis. It 
is manifest that under these conditions it is impossible to describe a 
disease the existence of which is still in doubt. 



SECTION Till. 

DISEASES OF THE RESPIRATORY SYSTEM. 

DISEASES OF THE NOSE AND NASOPHARYNX. 

Examination of the nose in infants and children should first 
include a general inspection of the organ. In this way any con- 
genital deformity, particularly of the septum nasi, is noted. Some 
forms of congenital syphilis carry with them a malformation of the 
bony septum, by which the bridge of the nose is markedly depressed 
in very much the same manner as that of the adult. Deviations of 
the bony septum are sometimes indicated by an angular deflection 
of the organ to one or the other side. The interior of the nares may 
be inspected, as in the adult, by elevating the tip of the nose upward 
and backward, or by means of small-sized specula. 

One of the most useful methods with the author of discovering 
any obstruction in the nares, especially in the newborn and young 
infant, in whom instruments, such as specula, cannot be applied, is 
the passage of a small probe into the nares in a backward direction. 
This procedure is painless, and in the majority of cases will suffice 
to discover any swelling of the mucous membrane or bony obstruc- 
tion, if such be present. The introduction of the index finger of one 
or the other hand into the nasopharyngeal space for the purpose of 
palpating the walls of this structure has been dilated upon elsewhere 
in discussing adenoids. In older children the inspection of the pos- 
terior nasal space by mirror, if this is possible, is much to be preferred 
to the digital examination. 

Acute Nasal Catarrh. — This is a common affection of infancy 
and early childhood. In the newborn it follows as a direct result of 
exposure combined with infection, either by the lochia of the mother 
or uncleanliness of the bath water. In older infants and children 
acute coryza occurs sporadically or in epidemic form. It is apt to 
be seen at certain seasons of the year — early spring or autumn — when 
children are subjected to sudden changes of temperature of the outer 
air and that of the living apartments. Infection by bacteria plays a 
leading role in this disease, as in other affections of the nasopharynx. 
Infants and children are apt to be infected by adults around them, 
especially careless nurses. One child may infect the other, or acute 
nasal catarrh may usher in the acute infectious diseases, such as 
measles, bronchitis, influenza, pneumonia, pertussis, and in some 

574 



DISEASES OF TEE NOSE AND NASOPHARYNX. bib 

cases cerebrospinal meningitis. One attack of nasal catarrh may 
lead to another, and thus, in the end, to chronic nasopharyngeal 
catarrh. Some infants and children have a tendency to contract 
coryza upon the least exposure to a cold or dust-laden atmosphere. 
Such infants and children are pale or rachitic or show some constitu- 
tional dyscrasia, such as lymphatism. 

Symptoms. — The symptoms of acute nasal catarrh, or coryza, con- 
sist in a slight discharge of a serous or seropurulent secretion from 
the nostrils. This discharge may be thin or mucoid in consistence, 
and may be small in quantity, occur in. the early morning, but slight 
in amount during the day. There is, as a rule, but little or no febrile 
disturbance in mild cases. In the severer types there may be in- 
volvement of the lachrymal ducts, with slight or marked redness of 
the conjunctiva, orbital and palpebral. In the latter form there is 
lachrymation and photophobia, with or without slight febrile move- 
ment. In other cases the infants or young children are uneasy, do 
not take their usual day naps or their food, and have a slight cough. 
An inspection of the fauces may reveal but little inflammatory reac- 
tion, and the tonsils may be enlarged to a slight degree. As a rule, 
all these organs are drawn into the picture. In some cases conjuncti- 
vitis may be the first symptom, and the nasopharyngeal catarrh may 
follow. Restlessness in some cases and temporarily high temperature 
are explained by an inspection of the drumhead of the ears, which 
may be slightly or even markedly red without bulging of that struc- 
ture. In other words, a myringitis may give rise to a temperature 
of short duration. 

Course. — As a rule, the affection is self-limited, lasts two or three 
days, and then retrogrades; in other cases the physician is annoyed 
at the persistence with which certain symptoms continue and refuse 
to recede with therapeutical measures. When the symptoms are 
apparently subsiding the temperature may suddenly rise to 10-i° F., 
and this in the face of the most trivial physical signs. In such cases 
an inspection of the ear-drum may reveal a slight or marked otitis. 
In the nursing infant the obstruction and swelling in the nose may 
cause difficulties in nursing, and the bowels may show slight evidences 
of infection, caused by the infant swallowing the discharges from the 
nasopharynx. 

Diagnosis. — This is not difficult, but in the face of any c< 
of an acute type the patients should be examined as to the presence 
or absence of measles, bronchitis, pneumonia, or otitis, especially if 
a temperature of a high intermittent typo is presenl after the second 
day of the disease. 

Prognosis.' — The prognosis is good, but it is not invariably so, as 
to a rapid termination in an uncomplicated recovery. During the 



576 DISEASES OF THE RESPIRATORY SYSTEM. 

early spring an acute coryza is not infrequently followed by an otitis, 
which may be catarrhal, purulent, or even eventually involve the 
mastoid. We should therefore not regard lightly any coryza in an 
infant if the symptoms persist beyond the third day, and other organs, 
such as the ears or bronchi, become involved. 

Treatment. — The mild forms of acute nasal catarrh in infancy and 
childhood are self-limited as to duration, and simple cleanliness with 
nursing will in most cases suffice in the treatment of the disease. In 
infants the nose should be carefully cleansed with a spud of cotton 
after the morning bath, and then a drop of castor oil allowed to flow 
back into the nares. If this one application does not suffice to keep 
the nares clear of secretion, and nursing is difficult on account of the 
accumulation of secretion in the nares, this procedure must be re- 
peated during the day. Mild cases need no medicinal treatment. If 
the throat is drawn into the picture, a small dose of 2 or 3 minims 
of the tincture of the chloride if iron combined with glycerin may 
be given every three hours. If there is much conjunctivitis a satu- 
rated solution of boric acid flushed in the eye two or three times daily 
is, as a rule, efficient ; and in the subacute stages of the conjunctivitis 
a drop of a solution of sulphate of zinc, 2 grains to the ounce, may be 
instilled into the eye once or twice daily. 

The application of a copper pencil to the conjunctivae once in the 
subacute state is advised by some, though the author thinks that such 
procedure should be carried out by the oculist. The reaction which 
follows the application of copper subsides soon, to leave the con- 
junctivas in a less angry condition. If an inspection of the ear-drum 
shows a redness without bulging of the drumhead, we may temporize, 
and if there is reason to believe that pain is present, a drop of warm 
hyoscyamus oil instilled into the ear once or twice daily will give 
relief. Marked otitis requires more elaborate treatment, which should 
be carried out by the otitic specialist. 

Sprays and douches are not applicable to infants and young chil- 
dren, on account of the resistance made by these patients to any 
therapy of this kind. Only older children can be taught to gargle 
or spray. Where this is possible a mild solution of listerine or 
Dobell's solution is all that is called for. I have never found it 
necessary to use stronger drugs in children. If temperature is not 
present, the open air is certainly not contraindicated ; on the con- 
trary, it may cut short a rebellious catarrh. 

Chronic Nasal Catarrh. — This is a condition found in infants 
and children, as a result of repeated attacks of acute nasal catarrh, 
in a constitution undermined by a pre-existent dyscrasia, such as 
lymphatism. In most infants and children this tendency to chronic 
catarrh is hereditarv. There are evidences in these little ones of 



DISEASES OF THE NOSE AND NASOPHABYNX. 577 

similar conditions elsewhere. Such infants and children may suffer 
from forms of conjunctivitis. Keratitis, dermal eczema, or erup- 
tions of various kinds, anaemia, adenoids, nasal polypi, deviated nasal 
septum — may be combined with hypertrophy of the nasal mucous 
membrane. A chronic nasal discharge is present, and with it erosion 
of the nostrils and a distinct odor to the breath (ozasna). The tonsils 
in this stage are enlarged. Foreign bodies may set up a chronic 
inflammatory condition of the nares in children suffering from chronic 
catarrh ; this fact must never be lost sight of. 

Symptoms. — Symptoms of chronic nasal catarrh are combined 
with certain chronic hypertrophic conditions of the throat and naso- 
pharynx. Thus, very young infants, unless they are subjects of 
syphilis or adenoids, are not chronic sufferers from nasal catarrh. 
There is then a constant discharge from the nose and the nasopharynx. 
In older children, from five to eight years of age, the hypertrophy 
of the nasal mucous membrane and the nasopharynx results in a 
profuse mucopurulent secretion in the pharynx and nose. 

These children have a constant cough, and are subject to repeated 
attacks of so-called cold, the tonsils being enlarged, the lymph-nodes 
at the angle of the jaw are also enlarged, as also the nodes of the 
neck behind the sternomastoid muscle, and elsewhere in the body. 
The alse nasi are thickened and reveal erosions. The lips are also 
thickened as the result of obstructed circulation. Breathing is mostly 
oral. An inspection of the fauces shows the posterior pharyngeal 
walls coated with mucopus and studded with hypertrophied struc- 
tures made up of lymphoid tissue called follicles. In older children 
these symptoms may be combined with symptoms of atrophic rhinitis, 
in which the mucous membrane of the nose loses its hypertrophic 
appearance and becomes thin, atrophic, and coated with dry greenish 
crusts. Instead of obstruction there is found a wide nasal passage, 
and there is distinct odor to the breath and nasal discharges. There 
are forms of chronic nasal catarrh in which the above symptoms are 
present to a very mild degree. 

Thus, with the nasal catarrh there are enlarged tonsils and a few 
adenoids, and only an occasional odor to the breath. This condition 
is found in children who have been treated with indifferent success. 
The very marked cases of nasal catarrh in lymphatic subjects may 
be combined with a conjunctivitis of a chronic type or granular lids 
and eruptions, such as ecthyma and pustular eczema of the chronic 
type, all of which indicate the presence o( a dyscrasia. 

Treatment. — The treatment of the above conditions arc first local; 
the tonsils and growths in the nasopharynx must cither be removed 
or treated locally. The minutiae o( such treatment belongs to the 
realm of nasal specialism. The local treatment must, however, be 

37 



578 DISEASES OF THE EESPIEATOEY SYSTEM. 

combined with general constitutional hygiene and treatment. The 
remedies best suited to the conditions above are discussed under the 
heading of Scrofulosis and Lymphatism. 

Diphtheritic Rhinitis. — An apparent simple rhinitis of a catarrhal 
character may in a short time take on the characteristics of a diph- 
theritic process, due to an infection with the Klebs-Loffler bacillus. 
There is a profuse seropurulent or serosanguinolent discharge from 
the nose, with shreds of pseudomembrane, erosions of the nares, and 
extension of the membrane backward to the nasopharynx and down- 
ward to the larynx. This true diphtheria is accompanied by the 
glandular swellings and constitutional symptoms characteristic of 
the disease elsewhere. On the other hand, there is a form of rhinitis 
called pseudomembranous rhinitis, in which the disease remains 
fairly limited to the nose. 

There are two forms of pseudomembranous rhinitis, the truly 
diphtheritic form, in which the Klebs-Loffler bacillus is an etiological 
factor, and the streptococcal form, both of which have a similar 
symptomatology. The form of disease to which we refer is mild in 
its course, and begins like a catarrhal rhinitis, but on the third day 
a white coating is formed over most of the inflamed area; that is, 
on the turbinated bodies and the septum of the nose. This coating, 
which is pseudomembrane, cannot be either washed off or wiped 
away with absorbent cotton, but may be peeled off with the forceps. 
As soon as the membrane is removed, however, it reforms ; it is dead 
white and opaque, and firmly attached to the parts beneath, and, 
when detached, considerable violence must be used, and a bleeding 
surface is left. 

Treatment. — In some cases casts of pseudomembrane may be re- 
moved from the nostrils. Chapin, Bresgan, Schuler, Hartmann, 
and Muldenhauer have all described these cases. This membranous 
condition lasts in some cases from twelve to fourteen days, and 
though, as has been intimated, some of them must be looked upon as 
true diphtheria, the prognosis is generally good. In the streptococcal 
cases the prognosis also is good. We must never forget, however, 
that though there is in a certain proportion of cases of membranous 
rhinitis very few constitutional symptoms, and very little tendency 
of the disease to spread downward from the nasopharynx to the 
larynx, these cases should always be examined for the presence of 
the Klebs-Loffler bacillus, and if found should be treated as a diph- 
theritic process. 

Foreign Bodies in the Nose. — Children are prone to put beans, 
buttons, pins, and foreign bodies of all kinds into their noses. These 
foreign bodies at first cause little disturbance ; after awhile, however, 
they become a source of pain and irritation, and, if not discovered, 



DISEASES OF THE NOSE AND NASOPHARYNX. 579 

chronic nasal catarrh, ulceration, and even abscess may result. The 
removal of foreign bodies from the nose in many cases requires noth- 
ing more than ordinary skill. Some children can be taught to blow 
the foreign body out of the nostril by occluding the unobstructed 
nostril with the fingers. In other cases the foreign body can be re- 
moved with the forceps. In the third set of cases, a scoop introduced 
into the nostril so as to hook the body posteriorly is an efficient means 
to remove it ; in other words, a bent probe or buttonhook. 

Epistaxis. — Epistaxis is rare in the newborn, except as a mani- 
festation of syphilis or sepsis. In infants and children it may be 
caused by traumatism of any kind, and is seen mostly in school chil- 
dren who have been confined in warm rooms and have developed 
nasal catarrh with or without adenoid vegetations. There may be in 
these cases small ulcers or erosions of the septum nasi. Epistaxis 
occurs in the course of acute or chronic rhinitis, typhoid fever, pneu- 
monia, infectious diseases, diseases of the heart, chlorosis, haemophilia, 
scurvy, morbus maculosus, and finally, it occurs in young girls enter- 
ing on the period of menstrual activity. It may occur in these sub- 
jects also as a vicarious form of menstruation. 

Epistaxis, as a rule, is unaccompanied by any symptoms other 
than those of the bleeding, in drops, from the nose. In very few 
cases does this hemorrhage become alarming unless there is a history 
of haemophilia. The quantity of blood lost is often exaggerated by 
the patients, and rarely exceeds an ounce. Nasal hemorrhage may 
occur daily, or it may recur every few days or weeks, in which case 
there is always a suspicion either of traumatism, such as picking the 
nose, or a chronic nasal catarrh. Some children complain of dizzi- 
ness or vertigo preceding the attack. Others become greatly alarmed 
by the sight of blood. 

Children below the age of three or four years rarely have epis- 
taxis except as a result of traumatism or nasal ulceration. In some 
cases hemorrhage is really alarming, amounting to a rhinorrhagia. 
In these cases there is a suspicion of dyscrasia ; in many cases blood 
may during sleep flow down the posterior nares into the oesophagus 
and stomach, and after a time the clotted blood may be vomited or 
passed in the movements, thus simulating hemorrhage from the 
stomach or bowels, and in young infants mehrna. 

Adenoid Growths (Adenoid Vegetations). — Adenoid growths are 
masses of hypertrophied lymphoid tissue found in the vault oi the 
nasopharynx. In 1808 Meyer of Copenhagen first drew attention 
to adenoid growths as a clinical entity. Since then the increased 
importance of a recognition and study of these growths has become 
quite evident. 

Occurrence. — They occur in persons oi' all climes and countries but 



580 



DISEASES OF THE RESPIRATORY SYSTEM. 



are less prevalent in warm climates and in high and dry mountainous 
districts than in cold and damp countries. The adenoid growths 
occur at all ages from the newborn infant to old age. The greatest 
frequency according to all statistics is from the sixth to the tenth 
year of life. Of 4000 cases Wingrave found 1144 to occur at this 
period of childhood. 

Situation. — Adenoid growths are found on the posterior, superior 
and lateral walls of the nasopharynx. They are met most frequently 
in the so-called fornix of this space. They may be grouped around 
the openings of the Eustachian tubes. They have a crostate, cylin- 
drical or flat form. They thus are nothing more or less than the 
hypertrophied pharyngeal or Luschka's tonsil (Fig. 116). 

Etiology. — The true cause of 
FlG - 116 - adenoid growths is still a matter 

of speculation. They are found 
both in breast-fed and artificially 
fed children, but undoubtedly ac- 
company a so-called lymphatism 
prevalent in some families as well 
as children. There is also a heredi- 
tary element in the etiology of 
many cases. An infection of some 
kind is the starting point. This 
results in a chronic catarrh of the 
nasopharynx which favors hyper- 
trophy of adenoid tissue. If the 
nasal and pharyngeal passages are 
congenitally narrow and conditions are not favorable to the clear- 
ing out of contained secretions, then the elements arise which favor 
hypertrophy in keeping alive inflammatory conditions in those parts. 
An investigation into their nature by Macfayden and Macconkey 
has revealed the occasional presence of tubercle bacilli, but not to 
any greater extent than would be called accidental, in the face of 
tubercle bacilli in neighboring organs, such as the lungs or larynx. 
The acute infectious diseases, such as measles, scarlet fever, diph- 
theria, or any disease in which there is accompanying catarrh and 
inflammation of the tonsils and structure of the nasopharynx, are 
followed by a subacute catarrhal condition of these parts which ulti- 
mately results in the formation of adenoid growths and enlarged 
tonsils. 

Symptoms. — The symptoms may be grouped under four heads : 
rhinitis or nasal discharge, snoring, mouth-breathing, and vocal 
defects. 

Rhinitis. — A nasal discharge is a constant symptom of adenoids. 




Adenoid growth with centimetre scale. 
Shows lobulated structure. 



DISEASES OF TEE NOSE AND NASOPHARYNX. 



581 



Even to a mild degree it may be looked upon as presumptive evidence 
of their presence. With the nasal catarrh and discharge there arc- 
also attacks of epistaxis and earache which will be taken up later. 

Mouth-breathing. — Mouth-breathing, both by day and night, is 
almost a pathognomonic symptom. The peculiar condition of the 
mouth leads to a sort of adenoid facies, which is quite characteristic 
and easily recognized. With the facies, the open mouth, the thick 
lips, the sunken alas nasi, and in some cases eroded nostrils, the pic- 
ture of the adenoid sufferer is complete (Fig. 117). 

Fig. 117. 




Children with adenoid growths, marked and moderate in degree. 

Snoring. — Snoring, which occurs at night and in young infants, 
is a rattling noise in the throat which is due to ineffectual attempts 
at breathing. 

Speech.- — -The speech is affected and thick, the niceties of pronun- 
ciation in forming the letters m, s, ng, etc., are lost in an altered 
substitute which is more easily formed by the obstructed nasal and 
pharyngeal spaces. With the obstruction of the nasal passages comes 
an uneasy sleep and restlessness at night, with accompanying night- 
terrors. 

Lymphatism. — Many or most of these cases are anaemic, the 
ansemia being in part an expression of the general constitutional con- 
dition of lymphatism. 

Deafness. — Deafness is a final result of the ill effects of adenoids 
allowed to continue without treatment. Of deaf mutes fully 17 to 
70 per cent, have adenoids. 

Children suffering from adenoids hear very imperfectly at times 
and at others quite well. This is traceable to the condition of 



582 



DISEASES OF TEE SESPIBATOBT SYSTEM. 



catarrh in the nasopharynx as affecting the Eustachian tubes. Otitis 
is a frequent accompaniment of adenoids and recurrent otitis with 
persistent nasal discharge is not uncommon. 

Bronchitis. — In some cases the chronic catarrhal conditions in the 
nasopharynx cause a constant hacking cough and in many cases 
the catarrh passes down the respiratory passages, giving rise to bron- 
chitis or bronchitis of a chronic type, with emphysema and asthmatic 
attacks. 

Classes of Cases. — Clinically there are three distinct classes of 
cases that suffer from adenoids : 

The first class comprises those in which the adenoids cause few 
or no symptoms. The children when in good health breathe through 
the nose and keep the mouth closed during sleep. They are pecu- 
liarly susceptible to slight colds or catarrh, and when thus affected 

Fig. US. 




Enlarged tonsils enucleated entire in case with concomitant adenoid growths. 

the tonsils enlarge, the nose becomes obstructed by secretion, there is 
difficulty in breathing, and the patient sleeps with open mouth. On 
the subsidence of the inflammatory condition the normal status is 
re-established. The children are subject to recurrent attacks of ton- 
sillitis, and with each recurrence the symptoms of adenoids become 
more marked. The patients contract obstinate coughs which resist 
all treatment, and epistaxis occurs from causes apparently trivial. 

The second class of cases comprises those in which, in addition 
to enlarged tonsils, there are enlarged lymph-nodes in various regions 
of the body. The patients are pale and present all the symptoms 
of lymphatism. Their voices have a nasal intonation, the lips are 
always parted, and they sleep with the mouth open (mouth-breathers). 

The third class comprises the extreme cases of adenoids. The 
nasal passages are the seat of a chronic hypertrophic rhinitis, the 
tonsils are enlarged, there is obstructed breathing, and the mouth is 
always open. The infants and children make a peculiar snarling 
sound in breathing and have a stupid look. They are not neces- 
sarily lymphatic. Many children suffering from adenoids are slightly 
deaf, and all are subject to repeated catarrhal attacks (Fig. 118). 



DISEASES OE THE NOSE AND NASOPHARYNX. 583 

Between the extremes are seen all gradations of the affection. 
Many children who suffer from adenoids are well developed and in 
other respects perfectly normal. The deformities of the chest which 
have been ascribed to adenoids can hardly be so regarded. They are 
coincidental. Many of them are due to rachitis in early life and to 
unhygienic living. To trace enuresis, chorea, and masturbation to 
the presence of adenoids, seems also somewhat extreme. Adenoids 

Fig. 119. 




; 



Examination for adenoid growths. Position of patient and examiner. 

are an obstruction to the breathing, a menace to the hearing, and also 
a focus for repeated infections of the nasopharynx or the ears. These 
are sufficient reasons for their removal. 

Diagnosis. — The diagnosis is not 'difficult from the above set of symp- 
toms. Nasal polypi in older children, if they exist, may be seen in 
the nasal passages. A fibroid tumor o( the nasopharynx is hard and 
a malignant growth is scarcely probable as it is rare in infancy and 
childhood and gives a series of quite distinctive symptoms. There 
are enlarged tonsils ; they are probably accompanied by adenoids. If 



584 DISEASES OF TEE EESPIEATORY SYSTEM. 

on inspection of the posterior nasopharyngeal wall there is an en- 
largement of the follicular adenoid structure of the mucous mem- 
brane it may well be surmised that adenoids exist higher up. 

Method of Examination. — An inspection of the nasopharynx may 
be made by the rhinoscopic mirror or the nasopharyngoscope, recently 
devised by Hays, or by digital exploration. Ehinoscopy is only 
feasible in older tractable children, as is also the nasopharyngoscopy. 
Accordingly, in infants and children the digital exploration alone is 
feasible. The finger-nail of the index finger of the right hand is 
scrupulously cleaned and trimmed so as not to traumatize the parts 
and infect them. The physician " stands behind the patient, who is 
seated in a chair. The child is told to open the mouth and the 
thumb of the left hand presses the left cheek between the teeth. The 
index-finger of the right hand is carried round the soft palate into 
the nasopharynx where the finger will come in contact (if adenoids 
be present) with a variable soft mass which bleeds readily. With 
practice this examination can be conducted so expeditiously that the 
child has not got time to struggle or get frightened" (G. A. G. 
Simpson) (Fig. 119). 

Indications for Operation. — Nursing infants who cannot nurse or 
in whom sleep is palpably disturbed should be operated upon without 
delay, as in these patients the operation is simple and is followed by 
immediate relief. The indications for removal of the growths, even 
if only small amounts of adenoid tissue are present, are in older chil- 
dren a persistent rhinitis or repeated attacks of acute rhinitis, inter- 
mittent attacks of deafness with pale retracted ear-drums, or exuda- 
tive catarrh of the middle ear, chronic aural discharge which will 
not improve, mouth-breathing, snoring at night, and backwardness in 
phonation; in young children a persistent dry cough or bronchitis 
or an irritable cough. Of great importance is the recognition of the 
fact that some obstinate ear-discharges will not yield to treatment 
until existing adenoids be removed. 

Prognosis. — The operation for the removal of adenoids is exceed- 
ingly simple and unaccompanied by danger to life. It should be 
borne in mind that any operation of this nature may be followed 
by infections, especially of the ears. In this respect no operator is 
exempt from the chagrin of finding occasionally a complicating 
otitis follow the operation. Adenoids are apt to " return " or grow 
after being removed ; a secondary operation then becomes necessary. 

Treatment. — When the diagnosis of adenoids has once been made, 
it is well not to temporize with douches and sprays, as this mode of 
treatment acts only in a cleansing manner and merely delays the 
ultimate necessity of removing the growths. This removal is so 
much in the domain of specialistic procedures that it is well for the 



DISEASES OF THE NOSE AND NASOPHARYNX. 585 

practitioner not to rely entirely on descriptive methods hut to see, if 
he can, the operation performed once or twice by an expert before 
resorting to a personal attempt. 

Contraindications to Operations. — The tonsils and adenoids bring 
portals of infection, there are certain states in which operations in 
this region may be followed by reinfection. Thus cases of chorea 
with endocarditis, if still active, should not be subjected to operation. 
The chorea is likely to recur with greater severity, and the danger 
of a renewed heart lesion is great. Children who are in the active 
stages of endocarditis or recently recovered should not be operated 
upon. In all these cases palliative measures, such as sprays and 
douches, should be employed until the conditions above mentioned 
are thoroughly quiescent. In one case of chorea I saw an operation 
for adenoids followed in three days by a chill and high fever, endo- 
pericarditis, chorea insaniens, and death within ten days. While 
such cases are exceptional, they teach the necessity of caution in 
deciding to operate upon the adenoids in chorea and heart cases. 

Acute Retropharyngeal Abscess (Idiopathic Retropharyngeal 
Abscess; Retropharyngeal Lymphadenitis). — The retropharyngeal 
space, according to Gillette, is the seat of lymph-nodes, which are 
intimately connected with the lymph-vessels and lymph-spaces of 
the tonsils, and also with the system of lymph-vessels of the soft 
palate, these being also connected with the deep lymph-nodes of the 
face and neck. Processes such as catarrhal angina, diphtheria, scar- 
let fever, measles, or any lesion of the mouth, are likely to involve 
the retropharyngeal nodes (Karewski). Sometimes only the lymph- 
nodes in the median line of the retropharynx opposite the base of 
the tongue are affected. In this form the tumor in the midline is 
seen when the mouth is opened. In other cases several lymph-nodes 
are involved, and the process is then seen both as a swelling in the 
mouth and as an external swelling at the side of the neck. 

The swelling appears at or beneath the angle of the jaw, in front 
of or behind the sternomastoid muscles. Retropharyngeal abscess 
may occur in the following forms : 

1. Acute retropharyngeal abscess: 

a. That which points wholly in the mouth. 

b. That which points both externally and internally. 

c. That which forms a tumor chiefly external. 

2. Chronic tuberculous retropharyngeal abscess. 

3. Septic retropharyngeal abscess. 

This third class of retropharyngeal abscesses are those which 
complicate or follow the exanthemata, and which have a tendency 
to burrow downward, bursting into the mediastinum or to involve 
important structures, such as the Large arteries in the neck, thus 
causing fatal hemorrhage, A few such cases occur in the literature. 



586 DISEASES OF THE EESPIEATOEY SYSTEM. 

Frequency and Etiology. — Retropharyngeal abscess is peculiarly 
a disease of infancy and early childhood. The frequency diminishes 
in later childhood, the disease being rare after the fifth year. Of 
77 of my cases. 4 occurred between the first to the third month; 10 
between the third and the sixth month ; II between the sixth and the 
twelfth month : 19 between the first and the fifth year, and the 
remainder after the fifth year. One infant was only one month of 
age. and in two cases the patient was two months of age. The figures 
correspond to those of Bokai. The frequency in early infancy is 
probably explained by the structure of the retropharyngeal lymph- 
spaces and the susceptibility of the lymph-nodes to suppurative infec- 
tions at that period of life. 

Simon has described the lymphatics in the retropharyngeal regiou 
of infants and children as forming a small network of lymph-vessels 
and nodes on either side of the median line. This lymphatic net- 
work is situated between the superior constrictor and the aponeurosis 
of the prevertebral muscles. After the third year of life these 
lymphatics and nodes are said to disappear. This fact, as Blackader 
points out, would indicate a close connection between the time of 
activity of these nodes and the period when retropharyngeal abscess 
is most prevalent. It would help also to explain the absence of this 
form of abscess in older children and in adults who are frequently 
affected by tonsillar (quinsy) abscess. 

I have examined the pus from many of these abscesses, and found 
that it contains quite uniformly a streptococcus of the short or the 
long variety, not as a rule very virulent. It may be assumed that in 
all probability these bacteria are the essential cause of the abscesses. 
They gain access to the retropharynx either through the tonsils or 
the mucous membrane of the pharyngeal space. The abscess may 
thus be secondary to any form of inflammation of these structures. 
It occurs as a complication of simple tonsillitis, pharyngitis, influenza, 
or any of the exanthemata. 

Symptoms. — The symptoms of retropharyngeal abscess are not at 
first distinctive. The development of the abscess is insidious. At 
the outset there are the symptoms of ordinary tonsillitis or pharyn- 
gitis. The fever is high at the beginning. After the acute symptoms 
subside it is noticed that the lymph-nodes at the angle of the jaw con- 
tinue to be enlarged, and that the fever continues to show a remittent 
type. There is some prostration, the infant does not nurse prop- 
erly, cries, and is frequently restless. Inspection of the throat on the 
fourth or fifth day of a tonsillitis may reveal nothing except some 
swelling or oedema of the posterior pharyngeal wall or of the pillars 
of the fauces, no tumor being visible. After an interval of a few 
days, generally on the seventh or eighth after the initial symptoms, 



DISEASES OF TEE NOSE AND NASOPHARYNX. 587 

if is noticed that the voice of the infant has a nasal quality, that the 
head is thrown back, and that the breathing is noisy and nasal. 

Examination shows that the lymph-nodes at the angle of the jaw 
in front or behind the sterno-mastoid are swollen; inspection of the 
interior of the fauces shows a distinct swelling at the side of the 
pharynx pushing the tonsil and pillar of the fauces of that side 
forward. On introducing the finger a tense, fluctuating swelling. 
which may reach downward toward the larynx, can be felt. In other 
cases there is very little external swelling, and the internal tumor is 
situated nearer the median line, pushing the posterior pharyngeal 
wall forward. This swelling is covered by mucous membrane, is 
tense and fluctuating. If the tumor is allowed to increase in size, 
there is pronounced interference with the breathing. I have seen 
cases in rachitic infants in which the inspiratory sound was distinctly 
of a crowing character, showing incoordinate action of the vocal cords. 
These cases show great prostration and feebleness of pulse. 

Course. — If not treated, the abscess may press on the larynx and 
cause asphyxia, or may burst spontaneously into the larynx, suffo- 
cating the patient if it occurs during sleep, or may burst into the ear 
through the Eustachian tube and discharge externally. All of these 
results are rare if the abscess is detected in time for incision. 

Diagnosis. — The diagnosis of retropharyngeal abscess is difficult to 
the beginner, but is simple after the observation of one or two cases. 
The quality of the voice and the cry are so characteristic that after 
being once heard they are unmistakable. The breathing also is 
typical. The external swelling is present in most cases, and the head 
slightly retracted. Finally, digital examination should always be 
resorted to in all cases in which a slight or marked internal swelling 
is present. The index finger of the right hand is passed into the 
mouth and the posterior pharyngeal wall palpated. If an abscess be 
present, it will be apparent as a hard or tense, globular, deep or super- 
ficially fluctuating tumor. Care should be taken not to mistake 
the prominence of the body of the seventh cervical vertebra for an 
abscess. The bony tumor is deeper, as a rule, than the retropharyn- 
geal abscess, and is not fluctuating. All manipulation should be 
carried out gently, else the abscess may burst and suffocate the patient 
or rude exploration may cause a peculiar form of collapse which some- 
times follows digital examination in this region. 

Prognosis. — The prognosis of simple acute retropharyngeal abscess 
is good. Bokai lost only 4 per cent, of his cases. With early diag- 
nosis and proper treatment recovery is the rule. 

Treatment. The (real incut o( aeuie retropharyngeal abscess is 
Incision. This varies with the nature and location of the abs< ss. 
In the majority o( cases the abscess is near the median line, and its 



588 DISEASES OF THE EESPIEATOEY SYSTEM. 

wall is just beneath the surface of the mucous membrane. An in- 
ternal incision will then afford immediate and permanent relief. In 
other cases the abscess is at one side and internal, and may also be 
safely incised from within. In making an internal incision the fol- 
lowing method should be pursued : the child is wrapped in a blanket 
and held upright in the lap of the nurse, facing a good light. An 
assistant steadies the head from behind. The tongue is depressed 
with a tongue-depressor, and a bistoury, with the edge guarded by 
rubber plaster, leaving only a half inch of the tip exposed, is plunged 
into the most prominent part of the tumor. When the pus escapes, 
the incision is enlarged from above downward. The instrument 
should not be directed toward the side of the neck, for fear of wound- 
ing a vessel. 

As soon as the pus escapes freely the head of the infant is thrown 
forward and the pus allowed to drain into a basin, pressure being 
made from without, on the side of the neck. The internal incision 
should be made as rapidly and as gently as possible. I have seen 
death result within a few hours from aspiration of pus in a case in 
which an abscess burst as a consequence of rough digital exploration. 
If necessary, the incision may be enlarged with a dressing-forceps. 
In some cases the wound should be prevented from closing by intro- 
ducing the forceps daily. 

There is another class of cases in which the deep cervical glands 
at the side of the neck are involved and the abscess points partly 
internally and partly externally. In these cases it is unsafe to incise 
from within, nor is complete relief afforded by so doing. The 
abscess should be approached from without through a careful dissec- 
tion by a surgeon. The tuberculous abscess is due to spinal caries, 
and is best opened and drained from without, as are also septic 
abscesses. 

DISEASES OF THE TONSILS. 

The tonsils are really lymph-nodes, as has been shown by Stohr 
and Hodenpyle. In severe forms of inflammation they are enlarged, 
and the so-called crypts become plugged with bacteria and the products 
of inflammation (leucocytes, fibrin, serum). The crypts appear at 
the surface of the tonsil as yellowish specks. A catarrhally inflamed 
tonsil may not show them at the surface, because the products of 
inflammation do not coagulate, and are thus thrown off more readily. 
There is nothing specific about a lacunar or follicular amygdalitis. 
It is only a clinical picture of the large class of catarrhal inflamma- 
tions, in all of which the crypts and the tissue of the tonsil are infil- 
trated with inflammatory products. 



DISEASES OF THE TONSILS. 589 

- Acute Follicular Amygdalitis (Acute Catarrhal Tonsillitis; Acute 
Lacunar Amygdalitis; Catarrhal Angina). — Acute follicular amyg- 
dalitis is an infectious disease, communicable either through the 
secretions or by direct contact, as in the act of kissing. It occurs 
both as a primary and as a secondary affection. As a primary affec- 
tion, it occurs at all periods of infancy and childhood. It was 
formerly taught that follicular amygdalitis was rare in infants. 
This is scarcely true. Of 1284 cases of lacunar amygdalitis, 333 
occurred in infants under the age of twelve months, and 76 from the 
first to the fifth month; of the latter, only 5 occurred in the first 
month. It is frequent in children from the second to the fourth 
year, but is more common after than before the fourth year. The 
tonsils are secondarily involved in the exanthemata — scarlet fever, 
measles, and varicella — and in parotitis, influenza, pneumonia, and 
pertussis. In all these affections they are red, swollen, and in some 
cases present the appearance seen in the typical lacunar type of the 
disease. 

Etiology.- — The predisposing causes of catarrhal tonsillitis or 
lacunar amygdalitis are exposure to cold, traumatism, and the swal- 
lowing of corrosive or irritant substances. The exciting causes of 
follicular or lacunar amygdalitis and catarrhal amygdalitis are the 
Streptococcus pyogenes, the Staphylococcus pyogenes, and the pneu- 
mococcus. The diplococcus described by Roux is also found in the 
tonsillar crypts. 

Symptoms. — The affection rarely begins with a chill. The infant 
is restless, peevish, and wakeful at night ; it breathes rapidly, and 
there are high fever and marked prostration. Nursing is interfered 
with, not only on account of the pain in swallowing, but because in 
the majority of cases there is more or less rhinitis. The bowels are 
disturbed as a result of swallowing infectious secretions from the 
mouth with the food. The action of the bacteria is manifested in 
green stools, which are frequent and watery. Inspection of the 
throat should be conducted with patience and in a good light. The 
tonsils, normally very small, are seen to be enlarged and studded with 
whitish or yellowish-white points. The lymph-nodes at the angle of 
the jaw may be enlarged. 

In older infants and children the tonsils are enlarged, and the 
crypts plugged with inflammatory products. The surface of the 
tonsils is covered with mucopurulent exudate, or there may bo a small 
necrotic, ulcerated area in one of the tonsils. The neighboring struc- 
tures, such as the uvula, the pharyngeal mucous membrane, the 
pillars of the fauces, and even the larynx, may shavo in the catarrhal 
inflammation. The lymph-nodes at the angle o( the jaw may bo 
enlarged. The fever, as a rule, is high at tirst, ranging from 104 



590 DISEASES OF THE BESPIEATOEY SYSTEM. 

to 105° F. (40° to 4-0.5° C.) or above. The pulse is correspondingly 
rapid, and the respirations may be increased in frequency. 

The duration of a typical case of primary tonsillitis varies. As 
a rule, the temperature remains high for two or three days, with 
daily remissions. It then subsides and the patient convalesces. In 
some cases the temperature continues high for five or ten days, and 
then drops. In all of these cases there is some latent or apparent 
complication, such as retropharyngeal abscess, otitis, or, as has been 
recently pointed out by Packard and others, an insidious endocarditis. 

When otitis supervenes the tonsillar affection subsides. The 
fever, however, continues, with daily remissions. Infants and young 
children do not indicate the existence of pain in the ear. The 
patient is restless at night, and wakes with a start or in a peevish 
mood. In many cases the otitis can be diagnosed only by exclusion. 
In other cases the temperature continues high for a week or longer, 
reaching 103.5° F. (39.7° C.) during the day. The infant seems 
weaker, the tonsils are not enlarged or severely inflamed, the pulse is 
accelerated, and the respirations may number 40. In such cases the 
lungs show no sign of involvement, but careful examination of the 
heart will often reveal the presence of a systolic murmur at the apex 
and a slight increase of the area of cardiac dulness beyond the nipple. 
These are the so-called rheumatic cases. Frequently the urine shows 
a trace of albumin. In rare cases it contains in addition to the albu- 
min elements pointing to parenchymatous irritation of the kidney. 

I saw a case in a child six years of age, in whom, after a mild 
attack of tonsillitis, there were a few casts, blood-cells, and a small 
amount of albumin in the urine. Months elapsed before the urine 
ceased to show evidences of the nephritis. In these cases the albu- 
minuria may assume the so-called cyclic character. 

Prognosis. — The prognosis of simple catarrhal tonsillitis is good, 
recovery taking place in a few days. On the other hand, tonsillitis 
is not the simple entity formerly supposed. In infants and children 
this is especially true. The physician should be watchful for possi- 
ble complications and sequela?, such as otitis, retropharyngeal abscess, 
endocarditis, and nephritis. 

Diagnosis. — The diagnosis of tonsillitis is usually a simple matter. 
If an infant refuses the breast and the temperature is elevated, the 
throat should be carefully inspected. It is good practice to make a 
bacteriological culture with the secretions from the throat, even though 
the appearances are not diphtheritic at the first visit (for technique, 
see section on Diphtheria). 

Treatment. — The treatment of acute tonsillitis is symptomatic. 
Sponging with cold water or water at 85° F. (29.4° C.) containing 



DISEASES OF THE TONSILS. 591 

a -dash of alcohol, will lower the temperature. A dose of quinine 
should be given twice daily, and if the lymph-nodes at the angle of 
the jaw are enlarged, cold applications should be made externally. 
Sprays are not required unless there is a harassing cough. DobelFs 
solution sprayed three times daily will relieve that symptom. In 
nursing infants the number of feedings by the breast or bottle is 
reduced. 

If there is disturbance of the bowel, a teaspoonful of castor oil or 
grain -J (0.03) of calomel, given twice daily, will empty the bowel. 
The infant is then dieted on albumin-water or barley-water, or a solu- 
tion of acorn cocoa or beef-juice and barley-water, until the intestinal 
irritation has disappeared. A return to a milk diet may be made as 
soon as the movements become normal. Small doses of ferric chloride 
have a beneficial effect on older children. In mixture form it is an 
excellent local application to the tonsils. The custom of giving 
potassium chlorate in this mixture is now generally abandoned, the 
drug being highly irritant to the kidneys. In nursing infants ferric 
chloride causes diarrhcea. For this reason it should not be admin- 
istered to them for long periods. 

Herpes of the Tonsils. — Herpes of the tonsils are small vesicular 
formations seen on the anterior pillars of the fauces, just in front of 
the tonsils. They occur in a number of slight febrile conditions, 
may accompany an angina of a simple type, and are part of the clin- 
ical picture of aphthous stomatitis. The vesicles burst, leaving yel- 
lowish ulcerations of the size of a pin's head and surrounded by a 
pink areola. They heal without treatment after a few days. 

Ulceromembranous Tonsillitis or Angina {Associated with the 
so-called Fusiform Bacillus of Vincent). — This is a peculiar affec- 
tion occurring in children. At first one tonsil is affected, generally 
the right. After a few days the affection may spread to the other 
tonsil. Most of the cases I have seen were unilateral. In addition 
to the tonsillar ulcerations, a stomatitis of an ulcerative type is often 
present, and there may be ulcers on the tongue, cheeks and gums. 

The size of the tonsillar ulcer varies from that of a lentil to an 
involvement of a greater part of the tonsil, the shape of the ulcer- 
ation being irregular, and its character rather of a chancroidal typo. 
It has a worm-eaten base with sharp, overhanging edges, which may 
be slightly raised above the surface of the tonsil. The rest of the 
tonsil is but very slightly inflamed. The color of the ulceration i< 
a yellowish-green gray, or dirty brown, and from the first it appears 
as though the base of the ulcer were covered by membrane. The 
depth of the ulcer is quite considerable, varying from J to .1 inch. 
The submaxillary glands may be enlarged, or the lymph-nodes com- 



592 DISEASES OF THE BESPIBATORY SYSTEM. 

municating with the tonsil at the angle of the jaw may also be 
enlarged. 

Etiology. — The etiology of ulceromembranous tonsillitis or angina 
has been carefully worked out by Friihwald, Vincent, Lemoine, Abel, 
and in our own country by Sobel, Herrman, and others. This form 
of tonsillitis is caused by a bacillus, described more particularly by 
Vincent, and a spirillum. The bacillus is fusiform, about twice as 
long as the diphtheria bacillus, is pointed at both ends. Some of the 
bacilli are bent into crescent shapes. They vary in size, some being 
larger and thicker than others. The spirilla are long, corkscrew- 
like, with wide curves. They also vary in size, the larger and thicker 
ones staining more deeply. The bacilli and spirilla are motile. 

Symptoms. — This affection can scarcely be classed as one of the 
more serious affections of the tonsil, although at times of a subacute 
chronicity. The children are brought to the physician with a history 
of an ordinary sore throat, and when examined this ulcer of a deep- 
spread, pseudomembranous type is found on one or the other tonsil. 
The appearance is as if an irregular hole were punched out of the 
tissue of the tonsil. There is no spreading of membrane, nothing 
resembling diphtheria. There is slight fever, rarely higher than 
103° or 105° F. The symptoms at the outset are so mild that when 
the patient is brought to the physician the ulceration has taken place. 
In those cases in which there is accompanying stomatitis on the 
tongue, gums, or buccal mucous membrane, there is also fcetor of the 
breath. In some cases there may be pallor of a distinctly septic type. 

Diagnosis. — The clinical diagnosis must be made from that of 
diphtheritic ulcers, resembling very much what has just been de- 
scribed. Henoch and the author have described ulcers of a truly 
diphtheritic character very much resembling ulceromembranous an- 
gina. The only test is that of the culture-tube or the smear. An 
ordinary microscopical smear stained from the base of the tonsillar 
ulcer will reveal its true character if of the Vincent type. If the 
bacillus and spirilla are not evident at once, we should make a culture 
for the diphtheria bacillus. 

Prognosis. — The prognosis is invariably good; although in some 
cases the course of the disease is apt to become subacute, on account of 
the difficulty of reaching the base of the ulcer with remedies. Some 
cases may last as long as three weeks; others recover within a few 
days. Lemoine relates one case which lasted seventy days. 

Treatment. — The treatment is much the same as that of an ordi- 
nary tonsillitis. The tincture of the chloride of iron is given in 
doses of from 3 to 5 minims, combined with glycerin and water, every 
three hours. The base of the ulcer may be touched daily either with 
Lugol's solution or a 10 per cent, solution of nitrate of silver. 



DISEASES OF THE LARYNX. 



DISEASES OF THE LARYNX, 



Acute Catarrhal Laryngitis (Catarrhal Croup; Spasmodic Croup; 
Spasmodic Laryngitis; Pseudocroup) . — Etiology. — Exposure to cold 

or wet are predisposing causes. Like the majority of catarrhal in- 
flammations of the respiratory passages, acute catarrhal laryngitis 
is due to the invasion of bacteria. It occurs as a primary affection, 
and in a modified form is met with secondarily in measles and in- 
fluenza. The classical form of " croup" is a primary affection, and 
is most common from the second to the fifth year. It is also seen in 
very young infants. One attack predisposes to others. 

Symptoms. — Catarrhal croup or catarrhal laryngitis is an affection 
that causes much concern to mothers when a first attack develops 
without warning. During the day the infant may have had a mild 
coryza with a slight elevation of temperature. Toward evening a 
croupy cough, accompanied by croupy breathing or voice, suddenly 
develops. In some cases the symptoms remain mild, and only the 
cough disturbs the patients. They breathe freely, and dyspnoea is 
not marked. In other cases the infant or child goes to sleep free 
from alarming symptoms. Coryza may have been present unnoticed 
during the day. During the night the patient awakes with a croupy 
cough, which rapidly becomes worse. The breathing is noisy (croupy) 
and may be heard in an adjoining room. The cough is especially 
terrifying. 

The patients are restless, and cry during the paroxysms of cough- 
ing. In some cases they sit upright and gasp for breath. The face 
is pale and wet with cold perspiration. Fever may be slight or 
marked and may reach 104° F. In the majority of cases the 
dyspnoea is real ; there is drawing inward of the suprasternal region 
and the peri-pneumonic groove at the epigastrium. Toward morn- 
ing the dyspnoea, cough, and croupy breathing subside, and the 
patients fall asleep, worn out with the night's suffering. The next 
day the patients are apparently well, with the exception of a slight 
or marked croupy cough, coryza, swollen tonsils, with redness of the 
pharynx. For two or three successive nights or days there may be 
a repetition of the attack. This condition should be differentiated 
from laryngismus stridulus. In the latter there is no fever, the 
breathing is stridulous during only a short spasmodic attack, and 
there is no croupy cough. On the other hand, pseudocroup may 
occur in children who are rachitic and the subjects o\' laryngismus. 

There are forms oi' diphtheritic laryngitis without the formation 
of membrane, which in their symptomatology are identical with the 
form of laryngitis above described. This is true in very young 
infants and in children above five years of age. A culture-test is the 

38 



594 DISEASES OF THE BESPIBATOEY SYSTEM. 

only certain mode of differentiating the affections. The pathological 
condition giving rise to psendocronp is believed to be a swelling of 
the mucous membrane beneath the vocal cords. 

Diagnosis. — The diagnosis is not difficult except in cases in which 
the croupy cough, breathing, and stridor increase as the day or night 
wanes and no relief comes to the sufferer. In other cases the obstruc- 
tion to the breathing in the larynx increases as in truly membranous 
cases. Only a repeated culture will reveal the nature of such an 
affection, because one culture may be negative even in a truly diph- 
theritic case. In the severe forms of " croup," in the face of increas- 
ing laryngeal obstruction, the interests of the patient are best sub- 
served by assuming the presence of a diphtheritic process until the 
bacteriological culture proves the contrary to be the case. 

Prognosis. — The prognosis is good. I have never met a fatal case 
of non-diphtheritic catarrhal croup. On the other hand, many of 
these cases are due to a grippal infection. Such an infection may 
carry in its train complications, such as bronchopneumonia or ear 
affections, which may endanger the life of the patient. 

Treatment. — The patient is isolated, and placed under a tent im- 
provised over the crib. The tent is kept filled with steam generated 
by any of the devices for croup in the market (croup-kettle) ; the 
steam is saturated with turpentine, thymol, or benzoin. At intervals 
of an hour 10 grains of calomel are sublimed underneath the tent 
until the croupy cough and breathing abate. To relieve the laryngeal 
spasm, especially if there is a temperature, antipyrin, in doses of a 
grain to every year of the age, is efficient and induces rest and sleep. 
Antimony (Koo grain) combined with ipecacuanha (M.00 grain) 
may be given every two hours, or 20 drops of the syrup of ipecac 
every two hours until emesis occurs. Turpeth mineral is given by 
some to induce vomiting. I do not use the drug. 

If symptoms of progressive stenosis set in, intubation is justified, 
and in localities where bacteriological examinations are not feasible, 
diphtheria antitoxin should be administered, lest a membranous diph- 
theritic process be overlooked. I have seen cases, however, which 
developed cyanosis recover without intubation. It is questionable 
whether it is justifiable to allow the patient to suffer when such a 
simple means, as the introduction of a tube in the larynx, is feasible. 
The application of counterirritants to the larynx is of questionable 
utility. The same may be said of the application of heat or cold 
externally. 

(Edema Glottidis (Submucous Laryngitis; Phlegmonous Laryn- 
gitis). — Definition. — This is a serous or seropurulent infiltration of 
the submucous cellular tissue of the region of the upper larynx, or 
glottis, and the aryepigiottic folds. 



DISEASES OF THE LAEYNX. 595 

■ Etiology. — There are two forms — first, the simple serous infil- 
tration of the glottis; and, second, the inflammatory infiltration, the 
so-called phlegmonous laryngitis, in which the submucous connective 
tissue is involved. The serous form is secondary to and accompanies 
acute and chronic nephritis, infectious diseases, scarlet fever, variola, 
syphilis, typhoid fever, inflammation or ulceration of the structures 
adjacent to the larynx, especially of an erysipelatous nature. 

The second form, the phlegmonous laryngitis, is due to trauma- 
tism, such as the direct inhalation of steam, customary among chil- 
dren of the tenements when playing in the kitchen ; chemicals, foreign 
bodies, and injuries. 

Morbid Anatomy. — In the serous form of oedema glottidis the sub- 
mucous tissue is tense, infiltrated, pale or yellowish red; there is 
swelling of the upper laryngeal area. In the phlegmonous form the 
mucous membrane is dark red, swollen, covered with pus, and there 
may be ulceration of the mucous membrane of the larynx and vocal 
cords. 

Symptoms. — In the forms accompanying nephritis and the infec- 
tious diseases, the first symptoms to appear are those of stenosis of 
the larynx. In the traumatic form of phlegmonous laryngitis with 
consequent oedema of the glottis, especially in cases in which steam 
has been inhaled by children, there is pain in the mouth and pharynx, 
dysphagia, and dyspnoeic attacks. Inspection shows the mucous 
membrane of the mouth and pharynx to be inflamed and the tissues 
of the epiglottis swollen; and an inspection of the larynx reveals 
swelling of the false vocal cords and narrowing of the rima glottidis. 

Course. — The course of the disease depends on the nature of the 
primary affection. The milder cases, especially those accompanying 
acute or chronic nephritis, may retrograde. Other cases, especially 
the traumatic, if unrelieved, may result in fatal suffocation. 

Prognosis, — The prognosis must depend on the prognosis in the 
first form of the primary affection, and in the traumatic and phleg- 
monous forms of laryngitis the prognosis of the oedema glottidis 
depends on the severity of the disease. 

Treatment. — The treatment must consist, if a nephritis be present, 
in the treatment of the nephritis, and we must not forget that intuba- 
tion or scarification in children is in most cases ineffectual. Intuba- 
tion is apt to be ineffectual on account of the additional traumatism 
caused by the attempts at introduction of a tube, with consequent 
formation of false pockets. If the symptoms are such that suffo- 
cation is imminent, tracheotomy offers the simplest and safest means 
of relief. 

In many cases of oedema of the glottis, especially of the milder 
type, a small dose of the opiates will quiet the patient and have a 



596 DISEASES OF THE RESPIRATORY SYSTEM. 

tendency to relieve the apparent dyspnoea until such time as the 
symptoms of the primary disease retrograde. Especially difficult of 
treatment will be the secondary cases, with phlegmonous disease in- 
volving structures adjacent the larynx, such as angina Ludovici. In 
these cases the swelling of the structures may be so great as to make 
tracheotomy a very difficult operation. Intubation in these cases is 
scarcely to be thought of. 

Syphilis of the Larynx. — This affection is rare in infancy and 
childhood, inasmuch as it accompanies the later forms of syphilis. 
The seat of election of this disease is the epiglottis, where ulcers and 
condylomata are formed. The structures are thickened, inflamed, 
covered with white, diffuse patches, and the same changes are seen 
in the interior of the larynx as on the aryepigiottic folds. Cicatrices 
may form and cause marked symptoms of stenosis. Ulcers are seen 
on the back of the tongue and on the vocal cords. Gummatous infil- 
trations may form, ulcerate, and lead to inflammation of the cartilages 
and necrosis of these structures, causing stenotic symptoms. 

Diagnosis. — The diagnosis depends on a discovery of syphilitic 
lesions elsewhere. 

Prognosis. — The prognosis depends on how soon anti-syphilitic 
treatment can be inaugurated before ulceration and cicatrization 
results. 

Treatment. — The treatment of this affection consists in applying 
the anti-syphilitic remedies ; and when stenosis of the larynx occurs 
as a result of cicatrization and contraction of the structures of the 
larynx, intubation offers the most effective means of relief. 

Tuberculosis of the Larynx. — This is very rare in infancy and 
childhood, and is more common toward the age of puberty. It can 
affect any part of the larynx, causing hoarseness. It is rarely pri- 
mary, being, as a rule, secondary to tuberculosis of the lungs or other 
organs. 

Treatment. — The treatment belongs in the realm of special laryn- 
geal work. 

Growths in the Larynx. — The most common tumors found in the 
larynx are papillomata, granulomata, and fibromata. Malignant 
tumors are rare. Fully 25 per cent, of the papillomata are congen- 
ital, and manifest themselves from birth by symptoms of hoarseness 
and troubled cough. A frequent case of granulomata and papillo- 
mata of the larynx is recurrent laryngitis and operations upon the 
larynx, such as intubation or tracheotomy. 

Symptoms. — Tumors of all kinds cause hoarseness, accompanied 
by paroxysms of coughing with difficulty of respiration due to a cer- 
tain amount of stenosis, varying according to the size of the tumor. 
Some of these tumors may give rise to symptoms of suffocation. The 



DISK AX EH OF THE BRONCHI. 597 

granulomata which follow tracheotomy cause symptoms of asphyxia 
after the removal of the tube. 

In addition to the above symptoms, there are evidences, in all 
cases of tumor of the larynx, of catarrhal inflammation of the neigh- 
boring structures. 

Treatment. — The treatment of growths in the larynx belongs to the 
realm of throat surgery. 

Foreign Bodies in the Larynx. — During play children often aspi- 
rate bodies of all kinds into the larynx, and the symptoms caused 
depend very much upon the size and shape of the body aspirated. In 
rare cases the body lodges in the larynx, and may cause instant death 
by suffocation. Smaller bodies lodging in the ventricle of the larynx 
may cause attacks of dyspnoea, which subside when the patient takes 
the recumbent position ; but even these small bodies may cause instant 
death if they once lodge in the rima glottidis and close the opening 
of the larynx. Some of these bodies may after a time lodge in the 
bronchi and cause pneumonia. 

Prognosis.- — The prognosis depends upon the nature of the body 
and the possibility of dislodging it. 

Treatment. — If the body is small, it may sometimes be dislodged 
by standing the patient, as it were, on the head. It then emerges 
into the larynx and is coughed out. If such is not possible, it is best 
to locate the body by means of a radiograph, and then attempt its 
removal by the branchoscope and surgical means. 

DISEASES OF THE BRONCHI. 

Acute Simple Bronchitis.— Bronchitis, acute and simple, is an 
affection of the larger and medium-sized bronchi. In very young 
infants the disease is apt to be very severe and to attack the smallest 
bronchioles; it is then called capillary bronchitis. A capillary bron- 
chitis is really a bronchitis in which there is a certain amount of 
peribronchitic pneumonia. Acute bronchitis may occur at any period 
of infancy or childhood. It is, however, less common before the sixth 
month of infancy than during the period up to the third year, when 
its frequency diminishes. 

Etiology. — Bronchitis may be caused by an exposure to cold or 
wet or by traumatism to the mucous membrane of the air-passages 
through the inhalation of dust or irritating vapors. It occurs in the 
acute infectious diseases, such as malaria, scarlet fever, measles, 
rotheln, varicella, typhus and typhoid fevers, and frequently compli- 
cates pneumonia o( the lobular or lobar type. Rachitis and syphilis 
predispose* to attacks of bronchitis. The bronchitis o{ heart disease 
or nephritis should be regarded as o( a different class. 



598 DISEASES OF THE EESPIBATOEY SYSTEM. 

Pathology. — The bronchi may be filled with a mucous, serous, pur- 
ulent, or mucopurulent exudate, which is secreted b^ the epithelium 
of the mucous membrane and the mucons glands in the wall of the 
bronchi. In recent acute bronchitis the mucus is quite abundant. 
In the exudate on the mucous membrane of the bronchi and in the 
lumen, epithelial cells, leucocytes, and sometimes red blood-cells are 
found. The structure of the mucous membrane is infiltrated with 
small round cells to a greater or less degree. In some places the 
epithelial lining of the bronchi may be raised by exudate ; in others 
there may be loss of the superficial epithelium. If the bronchitis 
lasts any length of time, there may be atrophy of the structures of the 
mucous membrane. In the severer forms of bronchitis which affect 
the smaller bronchi the peribronchitic connective tissue is infiltrated 
with small round cells. In these cases there is an inflammatory 
exudate in the surrounding alveoli of the lung. There is then peri- 
bronchitis or bronchopneumonia. 

Symptoms. — In some cases the infant or child suffering from acute 
bronchitis will have a simple angina as an initial symptom. There 
is mild redness of the fauces with a slight rise of temperature which 
may last a day or more. The cough which was present at first per- 
sists, and there may be slight disturbance of the bowels, the move- 
ments are green and contain large curds of undigested matter. 

The cough may in aggravated cases give rise to occasional attacks 
of vomiting, especially immediately after nursing; at other times the 
coughing spells may cause the patient to cry. There is evidently 
pain, especially in the cases of bronchitis affecting the larger bronchi. 
The infant sometimes suffers from great difficulty in expelling the 
accumulated secretion. The attacks of coughing closely resemble 
those seen in old people who suffer from bronchitis. In many cases 
the infant or child is quite comfortable in the intervals between the 
coughing sjDells. In others the respirations are increased, and there 
may for some days be a slight evening rise of temperature, the 
patient showing signs of being seriously ill. In very young infants 
who are rachitic there may be a distinct drawing in of the sides of 
the chest and of the peripneumonic groove at each respiration. In 
cases of severe involvement of the smaller bronchi, there may be 
slight cyanosis of the lips and pallor of the surface. 

In the severer forms of bronchitis, especially of the grippal 
variety, there is a febrile temperature for several days. It may rise to 
102°-103° F. (38.8°-39.4° C), or even higher, with a correspond- 
ing increase in the number of respirations and the pulse-rate. In 
weak and very young infants there may be little or no cough. The 
infant lies in a soporose state, does not nurse well or refuses the 
breast. Older children may run about and play while suffering from 



DISEASES OF THE BRONCHI. DVV 

bronchial trouble; severe bronchial disturbance may appear to have 
little effect on the general health. Expectoration is exceptional; a 
frothy mucus collects about the lips of young infants after an attack 
of coughing. 

In older children it may be very difficult to collect sputum, even 
if they are old enough to understand the necessity of expectorating. 
The conclusion has been that children swallow the sputum ; it is more 
rational to suppose that the efforts at coughing are not equal to rais- 
ing any considerable quantity of secretion or that the amount of 
secretion in bronchitis is not so great as has been generally supposed. 
In many cases the cough is severer at night than during the day, but 
children cough and fall asleep immediately afterward, and therefore 
do not lose much rest. I have never met with a simple acute bron- 
chitis ushered in by a chill or convulsion. I have, however, seen 
severe forms of bronchitis cause petechial extravasations on the skin, 
similar to those seen in pertussis. The petechia are apt to occur 
about the forehead and eyes of very weak infants. 

Physical Signs. — In mild cases the number of respirations may be 
slightly above the normal ; in severer cases there are signs of dyspnoea 
and the respirations are increased in number. In very severe forms 
the peripneumonic groove may be drawn inward with each respira- 
tory act. In capillary bronchitis the lips may show some cyanosis, 
the surface may be pale, and the finger-tips slightly cyanosed. 

Palpation. — If the palms of the hands are placed on the anterior 
and posterior chest wall, the so-called rhonchal fremitus may be de- 
tected. The vibrations caused by accumulated secretion in the large 
and small bronchi give a sensation resembling that felt in stroking a 
purring cat. 

Percussion. — In simple acute bronchitis, percussion may elicit 
nothing abnormal. If infants have suffered from repeated attacks 
of bronchitis, the note may, owing to a slight emphysema, be hyper- 
resonant or vesiculotympanitic. In severe forms of capillary bron- 
chitis there may be areas of peribronchitic pneumonia or broncho- 
pneumonia, over which careful percussion will detect slight dulness 
with a resonant note. 

Auscultation. — In a number of cases, bronchitis at the outset. 
gives on auscultation nothing but a rude respiratory murmur which 
is more markedly puerile than normal. As the secretion accumu- 
lates there will be sonorous, sibilant, and crepitant rales, and also 
sonorous breathing. In the form called capillary bronchitis, with 
the subcrepitant rales there will be rales of much finer quality, resem- 
bling crepitant rales. The latter, which are unmistakable, are heard 
on inspiration, and appear to indicate areas of peribronchitic pneu- 
monia. In newly born and weakly infants there are, in this form 



600 DISEASES OF THE EESPIEATOET SYSTEM. 

of bronchitis, areas in which the air is not heard to enter the lungs 
(atelectasis). 

Treatment. — The treatment of simple acute bronchitis should be 
supporting and expectant. If the cough is harassing, a mild opiate 
mixture in combination with a small quantity of ipecac may be 
given. The following prescription has been found useful: 

I£ Tinct. opii caniph 3j (4.0). 

Syr. ipecacuanha- TTl xxxij (2.0). 

Syr. tolutani . . . §lj (60.0). 

Sig. Tea spoonful every three hours. 

The patients are allowed to be in the open air in fine weather, and 
the room should be well ventilated at night. In cases in which there 
is great relaxation of the mucous membranes, a dose of strychninae 
sulph., grain V200 (0.0003), may be given three or four times daily. 
The child is kept warmly clad, and wool is worn next the skin. 
Douching with cold water is to be avoided in acute cases. The oil- 
silk jacket may be worn, but it has no superiority to warm clothing. 
Applications of oil to the chest are of no value. The drugs of the 
coal-tar series (antipyrin or phenacetin) should not be used, except 
that one dose may be given at the very outset to relieve restlessness 
or headache. The bowels are relieved by means of calomel or a saline 
cathartic. 

In the subacute stage, syrup of ferric iodide may be given as a 
tonic for the mucous membrane. In rachitic infants and children, 
cod-liver oil is indicated. 

The treatment of so-called capillary bronchitis approaches very 
closely that of bronchopneumonia. The heart should be supported. 
Digitalis in the form of tincture is the most useful remedy. Strych- 
nine, caffeine, camphor, and musk in form of powder, all have here 
their legitimate sphere. 

The temperature, as a rule, needs no treatment. With older chil- 
dren, if the secretion is very profuse, carbonate of guaiacol is exceed- 
ingly useful and gives much relief. 

Fibrinous or Plastic Bronchitis. — This is a form of bronchitis in 
which membranous masses or fibrinous exudate are coughed up at 
intervals. These masses may have the form of the bronchi, or may 
consist of shreds or bands of membrane. 

Etiology. — Bronchitis of this form complicates diphtheria and 
pneumonia, and also occurs in the acute infectious diseases — measles, 
scarlet fever, tuberculosis, erysipelas, typhus and typhoid fevers. It 
is found in diseases of the heart and lungs, and may result from 
traumatism through the inhalation of poisonous gases. The above 
are the secondary forms ; the primary form of fibrinous bronchitis is 
obscure in its etiology, and is rare in infancy and childhood. 



DISEASES OF THE BRONCHI. 601 

Morbid Anatomy. --The casts which are coughed up are cylindrical 
in shape and branched in the form of the larger and smaller bronchi. 
The larger ones may be hollow and cylindrical, while the smaller 
ramifications may be solid or thready. In other cases the whole cast 
is solid; small air-bubbles may be confined in the fibrinous cylinders. 
The casts may be 10-12 cm. in length, the extremities being nodular, 
thready, or flat. Under the microscope they are seen to be formed in 
layers; in the centre of the oldest layers are found epithelium of the 
bronchi, leucocytes, and bacteria. Spirals formed of fibrin are occa- 
sionally found in the expectorated masses, especially in the diph- 
theritic, pneumonic, and the so-called idiopathic cases. 

Symptoms. — Attacks of Dyspnoea. — This form of bronchitis is 
characterized by attacks of dyspnoea and coughing. During the 
attacks clots of purulent fibrinous masses are expectorated, some- 
times with a slight amount of blood. In spite of the expectoration 
of blood there are no signs of tuberculosis. The presence of blood 
is probably caused by the detachment of the membranous casts from 
the walls of the bronchi. The expectorated masses may contain 
asthma crystals. In the intervals between the attacks, there may be 
symptoms of an ordinary bronchitis with mucopurulent expectora- 
tion, or there may be absolute freedom from symptoms. 

Cough. — The cough, which is present during the attacks, may be 
accompanied by a snarling or fluttering sound. 

Cyanosis. — Cyanosis may be present during the attack to a marked 
degree or may be absent. 

Fever. — Fever is present in the acute form, but has no special 
characteristics. 

Splenic Tumor. — Splenic tumor may be present. 

Physical Signs. — The physical signs of bronchitis may be present 
with rales of all kinds. If the membranous masses hang detached in 
the bronchi, a snarling or flapping sound may be heard on auscultation. 

The general condition of patients in the intervals and during the 
attacks varies greatly. » In some cases it is fairly good. 

Complications. — A tuberculous bronchitis or pneumonia may be a 
complicating condition. 

Diagnosis. — The diagnosis is made from the presence of the fibrin- 
ous casts. 

Treatment. — The treatment has thus far been very unsatisfactory : 
mercury, and also inhalations and sprays of all kinds have been tried 
in the acute cases. Iodide of potassium is of value in the intervals. 
If diphtheria is present, the antitoxin is given. 

Emphysema and Chronic Bronchitis of the Lungs. — Frequency. 
— Emphysema is a condition frequently seen postmortem in the lungs 
of infants and children (Steffen). No disease oi' the lungs runs 



602 DISEASES OF THE BESPIRATOBY SYSTEM. 

course without causing some emphysema. The condition is much 
more common in children than in adults, because it is favored by the 
peculiar structure of the lung in early life. Most of the forms of 
emphysema of the lungs of infants and children retrograde, allowing 
the lung to return to its normal state. Otherwise emphysema would 
be more common in adult life than it is. Clinically, emphysema 
combined with various forms of pulmonary disease, especially bron- 
chitis, is very common in infants and children. My experience in this 
respect confirms that of Steffen and Osier. It seems to be common 
to certain classes of children, especially those of rachitic tendencies. 

Morbid Anatomy. — Steffen has made a very careful study of the 
pathological condition in emphysema of the lungs of infants and 
children. The thorax has not the typical barrel shape seen in the 
adult, and occasionally found in older children. In younger chil- 
dren, especially those with rachitis, the sides of the lower portion 
of the thorax are incurved; the upper part of the thorax in front 
underneath the clavicles may be full and prominent. On opening 
the chest, the lungs are found to be inflated, to retain their form, and 
to show along the situation of the ribs a series of indentations due 
to pressure. The depressed portions may be denser than those raised, 
and show areas of circumscribed persistent pneumonia. In vesicular 
emphysema, air-vesicles may rupture into one another, giving rise to 
large sac-like formations which communicate with a bronchus. Some 
of the air-vesicles may rupture into the subpleural tissue. Vesicular 
emphysema rarely involves a whole lung or both lungs, but is localized 
to certain areas, such as the apices, anterior borders, or the lingula. 

The emphysematous areas are whitish, yellowish white, or red- 
dish yellow, the color varying with the amount of blood contained. 
They are raised above the surface, are elastic and velvety to the touch, 
and crepitate with the air contained. In children, in contrast to the 
condition in the adult, the heart is rarely dilated, and the liver and 
kidneys rarely affected. This is due to the temporary nature of the 
process. Bronchitis, trachitis, and laryngitis may exist as primary 
or secondary conditions. It is not possible to consider emphysema 
in infants and children as an isolated condition. Since it is most 
frequently seen in pronounced bronchial affections, it will be con- 
venient to consider it in connection with bronchitis. 

Symptoms.— Some infants and children suffer from a chronic 
catarrhal bronchitis which is more or less present at all times, and 
which may be interrupted by attacks of acute bronchitis. Infants 
and children thus affected are more or less rachitic; some have 
lymphatism in the form of chronic hypertrophic rhinitis and also 
adenoids or enlarged tonsils. In the intervals between the attacks of 
acute bronchitis, the patients do not seem to suffer much constitu- 



DISEASES OF THE BRONCHI. 



603 



tibnal disturbance. There is no fever, and no change in the respira- 
tion except that it assumes a noisy character. There is a cough 
which comes on at intervals, especially at night. The infants are 
pale, with rather flabby muscles, and may be fat, but impress the 
physician as being below the normal in point of strength. 

Physical Signs. — If the bronchitis has persisted a long time, the 
upper part of the chest is, even in infants under the age of twelve 
months, abnormally full. The upper costosternal region is high and 

Fig. 120. 




Emphysema of the lung in a boy eight years of a 

relative dulness. 



diminished cardiac area of 



the intercostal spaces are filled out. In milder cases there are no 
signs to be detected on inspection. 

Palpation. — There is distinct rhonehal fremitus felt anteriorly 
and posteriorly. 

Percussion. — If there have been a number of acute attacks, there 
will be emphysema of a vesicular type, giving a hyper-resonant note. 
In pronounced rachitis the hyper-resonance is apt to be marked. The 
area of relative cardiac dulness in older children is much diminished 
(Fig. 120). 

Auscultation. — Voice-sounds are normal. The breathing is rude 
or sonorous. The respiratory murmur may be prolonged. There 
are sonorous, mucous, and suberepitant rales. 



604 DISEASES OF TEE BESPIBATOBY SYSTEM. 

A second set of cases of chronic bronchitis comprises those in 
which a condition of pronounced emphysema of a vesicular character 
is present, and in which there are distinct attacks of dyspnoea or 
asthma. These cases must be differentiated from the purely neurotic 
cases of spasmodic asthma. The latter condition is rare in children, 
and is not accompanied by chronic catarrhal bronchitis. The history 
of these cases is one of repeated attacks of acute bronchitis. The 
lung may in the interval be wholly free from signs of bronchitis. A 
condition of this kind is apt to be left in the lung after a severe attack 
of pertussis. The infants or children may bear the marks of rachitis, 
and are usually anaemic. In the intervals between the acute attacks 
of asthma, the general condition is good. There is no fever ; there 
may be dyspnoea on exertion. An attack of asthma is precipitated 
by exposure to cold or wet. During the attacks infants and children 
do not suffer much, although they show signs of marked dyspnoea. 
There are none of the typical signs of an attack of spasmodic asthma 
in the adult. An infant showing very marked dyspnoea will play in 
the arms of the mother. The lips may be cyanosed and the surface 
pale and cool. There is no temperature. There is in these subjects 
a tendency to develop a cough of a laryngeal type on the least expo- 
sure. Examination of the chest shows nothing except a prolonged 
rude respiratory murmur, while percussion will give a hyper-resonant 
note over the whole chest. Suddenly an attack of so-called asthma 
will develop, with all the physical signs given below. The onset of 
the attack is sometimes signalized by a slight rise of temperature, 
100° to 101° F. (37.7° to 38.3° C.), and an increase in the number 
of respirations, 32 to 36 per minute. On examination, the chest 
shows all the signs of an acute attack of bronchitic asthma. An 
attack lasts for from a few hours to a few days. The children usually 
play about and seem little disturbed by their condition. 

During an Attack of Spasmodic Dyspnoea. — Inspection. — 
Inspection shows a drawing inward of the supersternal structures on 
inspiration, and a depression of the peripneumonia groove. The 
upper part of the chest is high and filled out, and moves little on 
inspiration and expiration. The lower part of the thorax has also, 
little movement. In rachitic children, there is not only drawing 
inward of the lower part of the thorax, but also a distinct incurvation 
of the lower ribs, caused by the repeated attacks of dyspnoea. The 
chest is moved as a whole. In children of seven or eight years the 
dyspnoea may be severe in the absence of cyanosis. These patients 
apparently suffer more than infants. 

In older children, the chest has the typical barrel shape seen in 
the adult sufferer from asthma (Fig. 120). In some cases there is 
a drawing inward of the intercostal spaces on inspiration. Some 
cases have a constant cough and frothy expectoration. 



DISEASES OE THE BRONCHI. 



605 



Palpation. — Palpation gives rhonchal fremitus and faint cardiac 
impulse. 

Percussion. — Percussion gives a vesiculotympanitic or hyper- 
resonant note over the whole chest, and cardiac dullness obscured and 
diminished by the emphysematous lung. 

Auscultation, — Auscultation gives a prolonged expiratory mur- 
mur and sibilant and sonorous rales. Heart-sounds are feeble. 

Between Attacks of Dyspnoea. — Between the attacks of dysp- 
noea the chest retains the above forms. There may be a slight con- 

Fig. 121. 




Emphysema of lung: boy eight years of age: barrel-shaped thorax. Same patient 

;is Fig. 12(1. 



stant dyspnoea or none at all. The patient feels quite well, and does 
not complain of the dyspnoea. The heart apex-impulse is diffused. 

Palpation gives little or no rhonchal fremitus. 

Percussion. — Percussion shows a note hyper-resonant, but not as 
markedly so as during the paroxysm of dyspnoea. Cardiac relative 
dulness is obscured by the presence of emphysema. 

Auscultation. — In older children the expiratory murmur may be 
prolonged or inaudible 1 . There are signs oi residua] bronchitis, sibi- 
lant, sonorous, and snberepitant rale-, and in young infants, large 
mucous rales. The signs may be hardly noticeable or beard only in 
certain port ions of the chest. 



606 DISEASES OF TEE BESPIBATOBY SYSTEM. 

Prognosis. — In both forms of chronic bronchitis the prognosis 
as to life is very good. The chances of ultimate restoration of the 
lung to the normal condition depend much on the mode of living 
and the power of the individual to outgrow the conditions of rachitis 
and lymphatism which exist in many of these cases. Many of these 
forms of chronic bronchitis disappear ultimately ; the emphysematous 
form may persist into adult life. 

Treatment. — The treatment of chronic bronchitis is directed to- 
ward improving the general tone of the economy and also the muscu- 
lature of the heart. It must be assumed that in these cases the heart 
as well as the other organs suffers from a lack of power, to which may 
be attributed the relaxed condition of the circulation in the mucous 
membrane of the bronchi. Life in the open air, hydriatic treatment, 
and drugs, such as strychnine, will have beneficial effects. The 
mucous membranes are benefited by preparations of iron which con- 
tain iodine (syrup of the iodide of iron), freshly prepared and given 
in large doses. Cod-liver oil is an excellent tonic in winter. The 
skin should be protected from extremes of heat and cold by suitable 
underwear. Moderate participation in sports in the open air im- 
proves the action of the heart. Running and gymnastics are to be 
preferred to bicycle-riding. 

A dry climate will do much toward improving the condition of 
the lung. During the attack of dyspnoea, iodide of potassium will 
be of service in alleviating the symptoms. This is the most useful 
remedy. It is also of great benefit when given in the intervals 
between the attacks. The other drugs used with adults are not indi- 
cated. An exception is Fowler's solution, which is an exceedingly 
useful remedy in moderate dosage in the intervals of the attacks, to 
be given, over a prolonged period. I have seen good results follow 
the use of digitalis in the form of the tincture, in combination with 
the iodide of potassium. The heart is thus greatly aided in improv- 
ing the circulatory conditions in the emphysematous lung. Rest 
from exertion is indicated during the attack, but patients may be kept 
out of doors if they will remain quiet. Codeine is most useful in 
allaying the cough. The administration of a large dose once or twice 
daily is preferable to giving small doses at shorter intervals. 

Bronchiectasis, Including Putrid Bronchitis. — Bronchiectasis, or 
dilatation of the bronchi, is not a very uncommon condition in infants 
and children. In most pulmonary disorders in infants and children, 
very slight dilatation of the bronchi may result. These have no clin- 
ical significance, and retrograde to the normal state in time. The 
marked dilatations are the congenital bronchiectasis and the acquired 
or inflammatory form. 

Varieties. — Congenital. — This is a condition in the newly born 



DISEASES OF THE BRONCHI. 601 

infant which has been known to persist into adult life (Grawitz, 
Welch, Kessler, Frankel). It generally affects one lung or a part of 
one lung. The lung structure is replaced by cystic formations which 
contain a serous fluid, in which are found nuclei and ciliated epithe- 
lium. The main bronchi may be cystic, with a system of minor cavi- 
ties separated from the main cavity by a series of septa. In this way 
numerous recesses are formed. The walls of the cysts may be cov- 
ered with several layers of cuboidal epithelium. ~No distinctive 
symptomatology has been reported in these cases. 

Etiology. — Whatever the exact cause of a bronchiectasis, there is 
certainly a diminished resistance of the walls of the bronchus to the 
inroads of inflammatory processes. In order to explain the imme- 
diate formation of these cavities, Hoffman has assumed that a stenosis 
of the lumen of the bronchus (as shown by Frankel and Lichtheim), 
must be produced by inflammatory processes and that under these 
conditions the repeated attacks of coughing produce dilatation. Such 
stenosis may have its origin in a peribronchitis or a pneumonia caus- 
ing thickening of the wall of the bronchus. Pleurisy, chronic pneu- 
monia, croupous or catarrhal, syphilis, and foreign bodies lodged in 
the lumen of the bronchi may be the direct cause of a bronchiectasis. 
Finally, there are the forms of bronchiectasis called primary, because 
their etiology has not as yet been explained. 

Inflammatory. — The inflammatory form of bronchiectasis may 
be sacculated, spindle-shaped, or cylindrical (vicarious). The cylin- 
drical bronchiectasis shows the bronchus dilated into a cylindrical 
form. This dilatation may merge gradually or abruptly into the 
main bronchus. The spindle-shaped bronchiectasis is only a form 
of the cylindrical variety. 

Pathology. — The sacculated bronchiectasis is the most common 
variety, and clinically the most important. It usually affects the 
smaller bronchi. A sac communicates with the trachea, and has no 
other outlet. The entry into the sac may be by way of a normal, 
a dilated, or a stenosed bronchus. If the infundibula are dilated, 
small cavities are formed (pulmonary vacuoles). In other cases the 
afferent bronchus may be obliterated, and the cystic formations are 
then of varying size. The wall of the bronchus leading to a cavity 
of this nature is in a state of catarrh, and may be thickened or infil- 
trated. The epithelium may be present only in spots. The infiltra- 
tion may affect the walls of the alveolar septa. The mucous mem- 
brane may after a time become atrophic. The .cartilages of the 
bronchi may also become atrophic and be replaced by connective 
tissue which may extend for varying distances into the lung sub- 
stance, forming trabecular The epithelium of the bronchi may be 
replaced by pavement epithelium. The mucous membrane becomes 



608 



DISEASES OF THE EESPIEATORY SYSTEM. 



thickened or is replaced by polypoid masses. The bloodvessels finally 
become dilated. There may thus be formed throughout the lung 
small aneurismal dilatations of the bloodvessels. The remaining 
lung tissue may be emphysematous or sclerosed as above. The pleura 
may be thickened. 

Symptomatology. — The symptoms include expectoration, a cough, 
dyspnoea, deformity of the chest, and fever. 

Expectoration.— There is expectoration of a mucopurulent char- 
acter, which cannot be differentiated from the expectoration of some 
forms of bronchitis. In other cases, large quantities of a fetid, puru- 
lent material are expectorated. This expectoration may at times be 
mingled with streaks of blood, or there may be a distinct hemorrhage, 



Fig. 122. 



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Bronchiectasis ; febrile and afebrile periods. Boy, seven years of age. 

resulting in some cases in a fatal haemoptysis. Sometimes the 
sputum is profuse, exceedingly fetid, fluid, and purulent, and will on 
standing separate into a serous and a purulent portion. 

Cough. — The cough may be occasional or, if the bronchiectasis 
exists in the apex of the lung, incessant. It is apt to be more marked 
in the morning, and may at that time be accompanied by the expecto- 
ration of the sputum accumulated during the night. At other times, 
change of position will cause paroxysms of coughing and the evacua- 
tion of large quantities of sputum. 

Dyspnoea. — Dyspnoea is present not only during the paroxysms of 
coughing, but also in the intervals, especially if there are extensive 
secondary changes in the lungs or pleura. 

Fever. — Fever of a hectic character is very likely to be present at 
times when the secretion in the lung accumulates. The temperature 



DISEASES OF THE BRONCHI. 609 

will then rise a degree or more, but subside when the lung is again 
cleared of bronchiectatic accumulations (Fig. 122). These rises of 
temperature may simulate those in the course of empyema or tuber- 
culosis. If abscess of the liver or kidney, endocarditis, or pneumonia 
occurs as a complication, the rise of temperature will be more marked. 

Deformity. — Deformity of the chest is apt to occur in severe cases 
in which there is emphysema of the lung or pleuritis. In 3 of my 
cases there have been deformities of the finger and toes. These, the 
so-called clubbed fingers, are not characteristic of bronchiectasis, since 
they are found in congenital cardiac disease and tuberculosis of the 
lung. There is pain as a result of existent pleurisy. Albuminuria 
may be present as a result of amyloid changes. Hsemoptyosis is 
generally a late symptom, but is not very common. Diarrhoea of a 
septic nature may occur in the course of the disease. 

Complications. — Complications include decomposition of the bron- 
chiectatic accumulations, pneumonia, gangrene of the lung, emphy- 
sema, pleurisy, empyema, perforation of the lung, laryngeal disease, 
kidney and heart disease, liver abscess, abscess of the brain, and 
finally amyloid degeneration of the liver, spleen, and kidneys. 

Diagnosis. — A positive diagnosis of bronchiectasis cannot always 
be made, especially in those cases in which there are all the signs of 
a localized empyema. Such cases show localized dulness or flatness, 
bronchophony, and absence of fremitus in a certain portion of the 
chest, generally at the lower portion behind. A needle, on being 
introduced, withdraws pus, which in the cases I have seen was min- 
gled with air bubbles. On operation, the pleura is found to be normal. 
In three instances I found this to be true. The evidence of a bron- 
chiectatic cavity lay in the persistence of signs and symptoms after 
the healing of the chest wounds. In all 3 cases the expectoration 
persisted in profuse quantities after operation (Fig. 123). 

Physical Signs. — The physical signs in all of my cases included a 
localized area of dulness or flatness, over which there was broncho- 
phony and bronchial breathing, in some cases with gurgles. Above 
this area, over the base behind, there was on percussion a tympanitic 
note, indicating the enlarged bronchus containing air. Tuberculosis 
is excluded by the absence of tubercle bacilli in the sputum, though 
bronchiectasis and tuberculosis may coexist. In most of my cases 
there was a history of an antecedent attack of pneumonia. Exclusion 
of abscess of the lung is very difficult in severe cases in which the 
quantity of sputum is excessive. The bronchiectatic cavity in these 
cases is very large. With the bronchiectasis, there may be diffuse 
bronchitis and emphysema of the lung. 

Course.- — Some of the eases in which the bronchiectasis is not 
marked or progressive result in spontaneous recovery. In others 

3D 



610 



DISEASES OF THE EESPIRATOKY SYSTEM. 



there may be tuberculosis, gangrene of the lung, or empyema, as 
complications. A fatal haemoptysis may close the scene of this very 
offensive affection. 

Treatment. — Treatment does not give very satisfactory results. It 
includes the inhalation of balsams of all kinds, out-of-door life in 
high altitudes, and surgical interference including exposure of the 
lung and incision of the bronchiectatic cavity. The latter is a des- 
perate remedy ; in some cases it has resulted in fatal hemorrhage and 
in others has not afforded relief. A cure has resulted in a few rare 

Fig. 123. 




Showing bronchiectatic cavity in case of a girl eight years of age, with signs as noted 

in text. 

cases in which there was a simple cavity in the lung near the pleural 
surface. The injection of these cavities with drugs has also been 
very unsatisfactory. 



DISEASES OF THE LUNGS. 

General Considerations. — The lungs at birth are small as com- 
pared to the other organs in the chest. They grow comparatively 
more in the first few months of infancy ; but in children they remain 
small as compared to the body-weight and length. Compared to the 
heart in volume during the first month of infancy, the lungs are as 
3.5 or 4 to 1. In the later months of infancy the lungs develop more 



DISEASES OF THE LUNGS. 



6 1 1 



rapidly, and then the ratio of volume of the lungs to the heart is as 
5.5 or 6.2 to 1. 

Movements of the Chest. — The movements of the chest may nor- 
mally he irregular in rhythm; the sides move in unison. 

In disease, especially in conditions of pressure on one side of the 
neck, one side of the chest may remain immobile, the other being 
retracted with each respiration to an exaggerated degree. I have 
observed this condition after operations for retropharyngeal abscess in 
the neck, in cases in which the nerves in this region were pressed upon 
or injured, thus interfering with the normal action of the diaphragm. 

In effusion into one side of the chest, there is diminished motion 
on the diseased side. Emphysema may restrict the normal movements. 

In forms of pleurisy with effusion the intercostal spaces are 
retracted more than is normal at each descent of the diaphragm. 
This may be due to adhesions. The precordial region may be drawn 
inward with the recoil of the heart, as is sometimes seen in adherent 
pericardium. 

Scoliosis of the spine may deform the chest, giving undue promi- 
nence to one side. Retraction occurs after the absorption of pleuritic 
effusions. 

Fremitus. — The method of obtaining fremitus in children has 
been described. It may be mentioned here that fremitus is well 
marked normally in the posterior axillary line and in the inter- 
scapular region. 

The Normal Limits of the Lungs. — In the mammillary line on 
the right side to the sixth rib; in the mid-axillary line to the ninth 
rib. Posteriorly on the right side to the tenth rib ; on the left side 
to the eleventh rib. Thus the limits are practically the same as in 
the adult subject (Symington). 

The amount of lung-tissue above the clavicle cannot be mapped 
out in infants and children. 

Resiliency of the Chest-wall. — The chest-wall in infants and chil- 
dren has a normal resiliency to percussion. The wall yields beneath 
the percussing finger. This is a definite feature. In any disease of 
the chest which interposes fluid between the chest-wall and the lung 
this resiliency of the wall is diminished or absent. In infants and 
children, as in adults, there are normally: 
Pulmonary resonance ; 
Dulness varying to flatness ; 
Tympanitic resonance. 

Pulmonary Resonance. — Pulmonary resonance is lower in pitch 
than in the adult. Anteriorly over the righl infraclavicular region 
it is less marked than on the lefl sido ; the note is also slightly higher 
and of shorter duration. 



(312 



DISEASES OF THE KESPIEATOEY SYSTEM. 



Dulness. — Dulness is found normally over the heart, liver, and 
spleen ; also, anteriorly on the right side from the fourth to the sixth 
rib. From the sixth rib to the borders of the ribs the note is flat. 
In the mid-axillary line on the right side there is dulness from the 
fifth to the seventh rib; from this point to the free border, the note 
is quite flat. On the left side at the level of the sixth rib, just above 
the spleen, there is a narrow strip of relative dulness, due to the pres- 
ence beneath the diaphragm of the left lobe of the liver (Fleischman) 
(Fig. 121). 

Pig. 124. 




Strip of relative dulness described by Fleischman, and found just above the spleen, sup- 
posed to be due to the presence of the left lobe of the liver. Child, two years of age. 



Posteriorly the supraspinous regions give dulness, but not so 
markedly as in the adult. On the right side, from the level of the 
seventh dorsal vertebra, extending downward, there is dulness cine 
to the liver. 



DISEASES OF TEE LUNGS. 613 

Tympanitic Resonance. — Tympanitic resonance due to the stomach 
is found normally in the left axillary line. It may in some cases 
extend high up in the axilla. 

Auscultation. — As a rule, there is little difficulty in obtaining the 
respiratory murmur and voice-sounds in infants and children — cer- 
tainly not in the latter. The crying of unruly infants is useful in 
that it gives the fremitus and the quality of the voice-sounds. In 
some cases the infants are very quiet during examination, and unless 
they are teased into crying, definite information on these points can- 
not be obtained. 

The Breathing.' — The repiratory sounds in infants and children 
are of an intensified vesicular quality; this so-called puerile breath- 
ing is normal and constant in children under twleve years of age. 
The quality of the vesicular murmur is probably caused by the better 
conducting qualities of the chest at this age. The elasticity of the 
lungs, which causes greater resistance to the inspiratory dilatation, 
is also a factor in producing the puerile quality of the respiratory 
sounds (Gutman). 

Types of Puerile Breathing. — Puerile breathing in infants and 
children may be classified as follows : 

a. The most common type is that in which the inspiration is 
coarse or intense in quality, while the expiration is vesicular and 
almost inaudible. 

b. The second type of puerile breathing is that in which the inspi- 
ration and expiration are both of an intensified coarse quality. 

c. The third type is that in which the inspiratory sound is low 
and vesicular, and the expiratory coarse and puerile. 

These types are found in infants and children at rest. If they 
are caused to cry, both the inspiratory and expiratory murmur are 
of a coarse puerile quality. In some infants and children at rest, 
the inspiration and expiration are vesicular as in the adult. Puerile 
breathing is frequently confounded with bronchial breathing. It is, 
however, never tubular in quality. Bronchial or tubular breathing is 
marked on expiration; puerile breathing is marked on inspiration. 

During auscultation the sides of the chest are always compared. 
On the right side, beneath the clavicle and over the spine of the 
scapula, the expiratory murmur is more intense 1 than on the left side. 
This should be especially remembered in cases in which disease of 
the right apex is suspected. The quality of the breathing in these 
regions approaches the bronchovesicular. 

Posteriorly, the respiratory murmur may be heard as far down as 
the level of the eleventh dorsal vertebra. In some children the 
sounds are not so intense toward the base 1 of the lung behind as 
higher up in the chest. 



614 DISEASES OF THE RESPIRATORY SYSTEM. 

Bronchovesicular Breathing. — Bronehovcsieular breathing is heard 
normally in the interscapular region in children as in adults. It has 
the same qualities as in the adult. 

Bronchial Breathing. — Bronchial breathing is heard normally over 
the trachea and upper part of the sternum. It is also called tubular, 
tracheal, and over the larynx, laryngeal breathing. 

Forms of Dyspnoea. — Though mainly of two types, pulmonary 
and laryngeal, dyspnoea may be caused by pain, fever, cardiac dis- 
ease, and abdominal tumors. 

Pulmonary. — There is not only an increase in the number of 
respiratory movements, but also a change in the depth of each respira- 
tory effort. In the dyspnoea of pulmonary disease, the region at the 
border of the ribs adjacent to the abdominal walls (peripneumonic 
groove) is drawn forcibly inward at each inspiration. In emphy- 
sema with asthmatic attacks, it will be noticed that during the attack 
the upper part of the thorax is immobile, the inferior part being 
drawn inward with each inspiratory effort. The presence of fluid 
in one side of the chest may be suspected if the side remains immo- 
bile, or if the intercostal spaces are drawn inward with each forced 
inspiration. A splenic or nephritic tumor may also, by simple up- 
ward pressure, immobilize one side of the chest. 

Laryngeal. — Laryngeal dyspnoea will occur in any obstructive dis- 
ease of the larynx. In addition to the phenomena of the pulmonary 
form of dyspnoea, there is a distinct retraction of the tissues at the 
situation of the suprasternal notch. There may also be laryngeal or 
croupy breathing. 

While this is true in the .majority of cases, I have also seen the 
retraction of the suprasternal notch, described above, present in the 
later stages of severe forms of acute pulmonary disease, especially in 
children; also in cases of emphysema in the asthmatic attack. 

Pain. — Pain will cause an increase in the number of respiratory 
movements. Thus the pain of an incipient pleurisy will cause an 
increased number of respirations which are more shallow than is 
normal. Peritonitic pain will also cause the respirations to become 
shallower and to increase in number. 

Fever. — Fever will, especially in infants and children, increase 
the number of respiratory movements to 40 or more, without the 
presence of any lung disease. 

Cardiac. — Cardiac dyspnoea is seen in those diseases of the heart 
which cause a retardation of the pulmonic circulation. The aeration 
of the blood in the capillaries of the lung is considerably interfered 
with under these conditions. Mitral disease, stenosis, and regurgi- 
tation cause dyspnoea not only for the reason given above, but also, in 
the later stages, on account of the bronchitis which is the result of 



DISEASES OF THE LUNGS. 615 

the cardiac disease. Anaemia of cardiac disease is also accompanied 
by a slight dyspnoea, which is especially marked in children. The 
slightest exertion will sometimes cause angina and dyspnoea in chil- 
dren suffering from a slight cardiac lesion. 

Ascites and Abdominal Tumors. — Ascites or abdominal tumors, or 
enlarged organs, such as the liver or spleen, will cause dyspnoea, 
especially when patients are in the recumbent position. 

In weak infants a few days old, who are the subjects of atelectasis 
and pneumonia, the upper part of the chest-wall moves very little, 
while the inferior portion of the chest and the upper part of the abdo- 
men (peripneumonic groove) are drawn inward at each inspiration. 

Lobar Pneumonia {Fibrinous Pneumonia, Croupous Pneumonia 
or Pneumonic Fever). — Lobar pneumonia or fibrinous pneumonia 
is an acute infectious disease, caused in the majority of cases by the 
Diplococcus pneumoniae (Frankel). A few cases are caused by the 
Bacillus pneumoniae (Friedlander) ; others, by the Streptococcus or 
Staphylococcus pyogenes. 

Occurrence. — Lobar pneumonia occurs as a primary disease or 
may complicate typhus fever, typhoid fever, influenza, rheumatism, 
malarial fever, erysipelas, osteomyelitis, meningitis, and nephritis. 
According to Keller, from 58 to 62 per cent, of all lobar pneumonias 
occur among children, the frequency among boys being greater (55.9 
per cent.). Fully two-thirds of the cases occur during the winter 
and early spring. Pneumonia of any variety, and especially of this 
form, may occur in groups of persons or in small local epidemics. 
Without doubt certain houses and rooms harbor the pneumonia poi- 
son for some time, as is evinced by the repeated occurrence of cases 
in certain places (Jiirgensen). Cold favors the development of 
pneumonia by reducing the resistance of the economy to the invasion 
of bacteria, but it cannot be regarded as a cause of the disease. 

Age. — Lobar pneumonia may occur at any age of infancy or child- 
hood. Von Jaksch has shown that it occurs among young infants. 
My own experience confirms this statement. Out of 839 of my cases 
of pneumonia of all types, 582, or 69 per cent., occurred before the 
end of the second year ; the greatest frequency was between the first 
and second years (282 cases). From birth to the sixth month the 
frequency is less than from the sixth month to the end of the second 
year. 

Sex, — The male sex shows the greater number of cases (436 
males, 403 females). 

Seat of the Disease.- — Jiirgensen shows that in 162 cases, both 
lungs were affected in 7.4 per cent. The right lung only was affected 
in 43.2 per cent, of the cases. When the right lung was attacked, the 
lower lobe was generally the seal o( the disease (25.3 per cent.). 



616 DISEASES OF TEE EESPIBATOEY SYSTEM. 

The lower lobe of the left lung was consolidated in 35 per cent, of 
the cases. 

Of 217 of my cases of lobar pneumonia, the right lung was 
involved in 124 cases and the left in 93; the upper right lobe was 
involved in 74 cases; the upper left in 35. The upper lobe of either 
lung was involved in 109 cases, as against 100 cases of the lower 
lobes. The middle right lobe was involved in only 8 cases. 

Upper lobe. Middle lobe. Lower lobe. 

Eight lung 74 8 42 

Left lung 35 — 58 

Pneumonia of the upper lobe is more frequent in children than 
in adults. According to Jiirgensen, the greater frequency of pneu- 
monia in the right lung may be attributed to the larger size of the 
right bronchus and the more direct communication with the lung. 

Morbid Anatomy. — Lobar pneumonia in infancy and childhood is, 
as in adult life, distinguished by the occurrence of a fibrinous exudate 
in the alveoli of the lungs, bronchioles, and lymph-spaces. This 
exudate is composed of desquamated epithelium, leucocytes, red-blood 
cells, and fibrin. The proportion of leucocytes, red blood-cells, and 
fibrin varies greatly at different stages of the affection. A fluid 
exudate may be present if the quantity of fibrin is small. In such 
cases there is a lobar catarrhal process or an inflammatory oedema of 
the lung. The exudate begins with congestive hyperemia. The 
lung is dark red and of increased consistency. With the appearance 
of coagulation there is produced a condition of hepatization in which 
the lung is solid, and has the appearance of liver. The bloodvessels 
are filled with red cells. If the vessels are less engorged, the lung 
has a grayish tint. 

This later stage, called gray hepatization, is the condition most 
frequently seen at autopsy. The hepatized lung does not contain 
any air, and on section shows a granular surface, the granules being 
the so-called pneumonic granules of the later stage of the disease. 
The pleura is as a rule inflamed. It is without lustre and may be 
thickened and covered with fibrin. There may be considerable serous 
or seropurulent exudate in the pleural cavity. The extent of hepati- 
zation varies. It may involve a whole lobe, part of the lobe of a lung, 
or parts of both lungs. On inspection of the surface of a section, 
small yellow areas may be seen in the hepatized portions. These 
are areas poor in fibrin, and correspond to the situation of the bron- 
chioles of the lung. 

The bronchial nodes may be red and swollen, the bronchi being 
the seat of inflammation. The bronchioles may be filled with fibrin 
and red blood-cells. 



DISEASES OF TEE LUNGS. 6 1 t 

Resolution occurs on from the seventh to the tenth day of the 
disease. At this time liquefaction of the inflammatory products 
which are eliminated by expectoration occurs. Complete restoration 
of the lung to the normal may occur between the second and the 
fourth week, at which time the periphery of the alveoli may be found 
to be rich in cells. There may still exist catarrhal processes which 
have succeeded the fibrinous changes. The pleura may remain thick- 
ened and be the seat of adhesions. 

An unfavorable or malignant ending, such as gangrene or suppu- 
ration, is rare, and is as a rule due to some mixed infection favored 
by an old bronchiectasis or putrid bronchitis. Unless a tuberculous 
infection occurs, caseation in lobar pneumonia is unknown. Indu- 
ration of the lung, cirrhosis or carnification, is a peculiar condition 
which may occur from the fourth to the tenth week. The lung 
assumes a beefy red appearance and is tough, hypersemic, and infil- 
trated with small round cells. The alveoli enclose a large number 
of connective-tissue cells. There is a proliferation of newly formed 
bloodvessels in the septa of the lung. The bronchial, peribronchial, 
and pleural tissues are proliferated. Induration of the lung by 
pleural adhesions results. The alveoli of the lung may be replaced 
by connective tissue and epithelium. Induration may take the form 
of bands of connective tissue, which may extend from the pleura into 
the lung, enclosing areas of lung-tissue. 

Bacteriology and Etiology. — The pneumococcus of Frankel is now 
recognized as the etiological factor in lobar pneumonia. The Ba- 
cillus pneumoniae of Friedlander is found in a small number of 
cases, with the pneumococcus or with other bacteria. The Strep- 
tococcus pyogenes and the Staphylococcus pyogenes are sometimes 
found, as well as the Bacillus typhosus. In the cases of secon- 
dary infection, the Diplococcus pneumoniae or the Staphylococcus 
pyogenes is found. In the majority of fatal eases, Kohn found the 
pneumococcus circulating in the blood. The cases which show the 
diplococcus in the blood and which recover, do so with complications. 
In a recurrent pneumonia of infancy, Perutz found an osteomyelitis 
of the joint, caused by pneumococci. In one of my cases which Avas 
followed by bilateral empyema, there was a peri-articular abscess con- 
taining pneumococci. According to Landouzy and Xetter. the pneu- 
mococcus is capable of producing suppuration without the interven- 
tion of streptococci or staphylococci. Cases of severe icterus are due 
to the hemolytic action of the pneumococci on the blood. Gaillard 
has shown that the enteritis in pneumonia is caused by pneumococci. 

Symptomatology.- —There are forms of fibrinous or lobar pneu- 
monia which present the same symptomatology in children as in the 
adult. On the other hand, certain sets of svmptoms referable to the 



618 DISEASES OF THE BESPIEATOEY SYSTEM. 

nervous system and intestinal tract, as well as the character of the 
variations in temperature, are peculiar to infancy and childhood. 

The disease may be ushered in by a chill, which may be severe 
or only amount to a sensation of chilliness. Susceptible subjects 
may, with the rise of temperature, be attacked with convulsions. 
Other patients pass into a stage of delirium lasting for days. Cases 
of pneumonia ushered in with cerebral symptoms are apt to mislead 
the physician, especially if meningitis has been recently prevalent. 
There are also cases, especially in children, in which there has been 
a preceding bronchitis. These should not be regarded as being of 
necessity cases of bronchopneumonia. Sometimes the chill is coin- 
cident with a sharp attack of enteritis. The character of the invasion 
will thus vary with the severity of the infection and the susceptibility 
of the subject. 

After the initial chill, there is in the simple cases a sharp rise of 
temperature. The height of the fever varies, and in young infants 
is apt to mount to 106° F. (41.1° C). There are cough and consid- 
erable dyspnoea, varying with the extent of lung involvement. 

In infants and children the dyspnoea is quite apparent to the eye 
of the observer, and will prompt him to surmise that the lung is 
involved. Older children have a distressed expression. In cases in 
which sopor is present, the dyspnoea is apt to be more evident than 
in those cases in which this cerebral symptom is absent. This appar- 
ent dyspnoea is only relative. A conscious patient does not show this 
dyspnoea as much as one who is unconscious. 

The patient complains of pain, which is in many cases referred 
to the side affected. In younger children the pain is quite frequently 
referred to the epigastrium, but sometimes to the region of the abdo- 
men low down, or to the right side of the abdomen low down over the 
situation of the vermiform appendix. Pain is apt to be referred to 
this region in cases of lobar consolidation of the lower portion of the 
right lung. These are often, in the early stages, diagnosed as cases 
of appendicitis. The face is pale or quite flushed. The dyspnoea 
may be slight, but is quite marked in some severe cases. Even if 
both lungs are involved, it may not be intense. 

There is a cough. In older children there is expectoration of 
rusty sputum. Infants and young children swallow the sputum. 
Infants cry with each paroxysm of coughing ; older children complain 
of pain. Sometimes infants and children vomit with each attack 
of coughing. After the fever has persisted with these symptoms for 
from five to nine days, there occurs in the vast majority of cases a 
fall of the temperature — the so-called crisis — which may take place 
within from three to six hours, or may extend over thirty-six hours. 
The fall of temperature may be followed by a temporary rise of a few 



DISEASES OE THE LUNGS. 



6 1 9 



degrees (Fig. 125) — the so-called pseudocrisis ; within a few he 
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Lobar pneumonia ; pseudocrisis and crisis. Leucocyte count before and after crisis indi- 
cated. Boy, four years of age. 



Individual Symptoms. — Temperature. — The temperature-curve in 
lobar or fibrinous pneumonia may be of several distinct types. In 
the majority of cases the temperature remains persistently high for 
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620 



DISEASES OF THE EESPIEATOEY SYSTEM. 



fection of the lung, but to a slight post-pneumonic toxaemia. The 
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Lobar pneumonia, right lung, lower lobe ; temperature falls by lysis. Leucocytosis indi 
cated in the chart. Female child, four years of age. 



Another very distinct form of temperature-curve is the remittent. 
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normal within a fraction of a degree. Such cases may also show at 



DISEASES OF THE LUNGS. 



621 



the terminal end of the curve a critical drop to the normal. In 
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takes place by what is known as lysis (Fig. 127). In other words, 
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begins at the ninth day of the disease, and is not completed until the 
fifteenth day. This is occasionally seen in cases in which there are 
apparently no complications. The more common type is that in 
which the lysis begins on the seventh or eighth day, and is completed 
in two or three days. Of 57 cases of lobar pneumonia in which a 
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Lobar pneumonia, right lung, middle lobe ; effusion into the pleura. Temperature after 
crisis due to pleurisy. Boy, eight years of age. 

to the ninth day of the disease (60 per cent, of my cases). After 
the lysis or crisis there may be a slight daily rise in temperature of 
a degree or even less, probably indicative of a very mild form of post- 
pneumonic pleurisy. The temperature in such cases falls gradually, 
and in four or five days reaches the normal (Fig. 128V 

The subnormal temperature after the crisis or lysis is quite a 
common phenomenon. I have learned not to fear this symptom, but 
to regard it as favorable (Fig. 120). A subnormal temperature may 
persist for days, or even a week or longer, and not uncommonly, espe- 
cially in fibrinous pneumonia which has run a sharp or moderately 
severe course, is accompanied by irregularity or abnormal slowness 
of pulse. A slow pulse (bradycardia) which is at the same time 
regular is apt to alarm the physician but 1 have never seen any ill 
elfoets in these cases if thev were treated in a rational manner. Such 
conditions of pulse ami temperature should be regarded as a result 
of the toxaemia which has affected the heart muscle. 



622 



DISEASES OE THE INSPIRATORY SYSTEM. 



Chills. — Chills, or chilly sensations followed by a rise of tempera- 
ture during the course of the disease, are in most cases accompanied 
by physical signs of an invasion of a new area of lung. This should 
at least be kept in mind, especially if the rise of temperature is abrupt. 

At the crisis in lobar pneumonia I have, in exceptional cases, seen 
the temperature drop within an hour from 103° to 94° F. (34.4° to 
39.9° C.) and the pulse to 48; within an hour the temperature rose 
to 96° F. (35.5° C.) and the pulse to 70. The temperature grad- 
ually rose, so that within seven hours it was again 99° F. (37.2° C.) 
in the rectum, the pulse 96. The symptoms of mild collapse may 
accompany the pronounced fall. 

Cough.- — Some infants and children cough very little; in others 
the cough is a very harassing symptom. There is no sputum even in 
the older children, or only after the crisis ; pain accompanies the 









































Fig 




129. 












































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Lobar pneumonia, right lung, upper lobe : remittent temperature-curve ; prolonged 
subnormal temperature intermittent in character ; recovery. Female child, two years 
and six months of age. 



cough, and may be suspected if the infant or child cries when it 
coughs. The pain is referred to the side of the chest, to the epigas- 
trium, or to the region of the umbilicus or appendix. The pain 
referred to the appendix in cases of lobar pneumonia is probably 
radiated from a diaphragmatic pleurisy. 

Dyspnoea. — Infants and young children show marked dyspnoea. 
The alse nasi are dilated and the peri pneumonic groove is depressed 
with each inspiration. In very severe dyspnoea in young infants, 
there may be a drawing inward at the suprasternal notch. This 
occurs even in the absence of any laryngeal disturbance, and fre- 
quently simulates laryngeal stenosis. 

Nervous Symptoms. — The cerebral symptoms may at the outset 
simulate those of meningitis (meningism). There are delirium, 



DISEASES OF TEE LUNGS. 623 

rigidity of the muscles of the neck, and even opisthotonos. There 
may be no true meningitis. Older children may have a low, mutter- 
ing delirium during the whole course of the disease. Near the crisis 
and just before the fall of temperature, I have in a few eases seen 
maniacal delirium, in which the patients were very noisy and at- 
tempted to get out of bed. I have seen cases of melancholia with 
crying spells during convalescence in female children, and also in 
boys. These symptoms all subsided in time and the patients were 
eventually fully restored. 

Blood. — It has been noted by Tumas and von Jaksch that in pneu- 
monia of the fibrinous variety there are a marked leucocytosis and an 
increase in the multinuclear leucocytes, which is especially marked at 
or near the crisis. The proportion of leucocytes to the red blood-cells in 
the cubic millimetre may reach 1 : 40 to 1 : 70. Ehrlich believes this 
leucocytosis to be a very constant occurrence in typical pneumonia. 
Billings has investigated the relationship of the leucocytosis to the 
prognosis more fully. His work will be referred to in the considera- 
tion of the prognosis. My own experience covers a large number of 
cases of fibrinous and bronchopneumonia, examined with reference to 
leucocytosis. Leucocytosis is present in both, forms of pneumonia in 
infancy and childhood, but is more marked in the fibrinous forms, the 
number of leucocytes to the cubic millimetre being about twice as 
great as in the catarrhal forms. There is marked leucocytosis in 
the fatal cases of both forms of pneumonia. 

The increase of the leucocytes in the fibrinous forms was espe- 
cially marked at the time of the crisis. In the bronchopneumonic 
forms the leucocytes were also high at or about the time of the drop 
in temperature. The diminution of the number of leucocytes was in 
both forms marked either just previous to or after the fall in the 
temperature. From the observations of Billings and Ewing, it must 
be concluded that leucocytosis is a favorable sign in fibrinous pneu- 
monia. It does not, however, as Ewing believed, bear any exact ratio 
to the extent of lung involved. I have found a much higher per- 
centage of leucocytes to the cubic millimetre in children than E wing- 
found in the adult. This is probably due to the fact that any leuco- 
cytosis is more marked in infants and children than in the adult sub- 
ject. The absence of leucocytosis is certainly a grave prognostic sign, 
but the presence of marked leucocytosis in children does not in my 
experience preclude a fatal issue. 

Physical Signs. — The signs obtained by physical examination of 
the chest in fibrinous pneumonia of infants and children resemble 
those of the same condition in the adult. In forms of bronchopneu- 
monia or catarrhal pneumonia in which areas o( considerable extent 
are consolidated the sie;ns \yill closelv resemble those obtained in the 



624 DISEASES OF THE BESPIBATOEY SYSTEM: 

fibrinous form. The physical signs of lobar or fibrinous pneumonia 
are classified as those of the first, second, and third stages of the 
disease. 

First Stage, Stage of Engorgement of the Lung. — On inspection 
the signs of dyspnoea above noted are found. 

Palpation at this stage will in an uncomplicated case give no signs, 
even over the affected area. If bronchitis complicates the case, rhon- 
chal fremitus may be obtained. At this stage the difference in 
fremitus between the affected and the unaffected side of the chest is 
not perceptible. 

In the first stage of the disease auscultation may discover a rude 
respiratory murmur on the healthy and diseased sides which is more 
marked in the latter and on inspiration. The pathognomonic sign at 
this stage is the crepitant rale, which is sometimes easily found and 
is at others very elusive. It may be present before an attack of 
coughing, and disappear after the bronchi have been cleared, and is, 
as a rule, heard over a very limited area. It is therefore necessary 
to examine the chest very carefully in front, behind, and in the 
axillary line for this sign, before deciding positively as to its presence 
or absence. It may be present for a few hours only. 

Percussion will at this period give slight dulness over the affected 
area of lung. The dulness may be slightly tympanitic. This is 
caused by the fact that at the outset of consolidation there is still 
some air in the affected area. Under these conditions there may be 
what is known as tympanitic dulness. This condition is especially 
found in young infants, in whom the chest-wall is thin, and in whom 
sounds are very well obtained by gentle percussion. 

Second Stage, Stage of Consolidation. — If the lower portion of 
the right lung is affected, we shall get by palpation in front over the 
upper part of the chest nothing abnormal ; over the lower part of the 
chest in front there will be an increase of the vocal fremitus, which 
is also apparent behind. Percussion over the upper part of the right 
lung will give a vesiculotympanitic note in front and behind. The 
unaffected side will give normal pulmonary resonance. In excep- 
tional cases the percussion-note over the upper lobe of the lung in 
front may give the so-called cracked-pot sound. In front, behind, 
and in the axillary line over the lower lobe which is affected there is 
dulness — not at first complete. ' When consolidation is complete, the 
dulness is quite marked. In cases in which some pleuritic effusion 
exists over the consolidated area behind, the percussion-note may be 
quite flat. In cases in which the upper lobe is consolidated there will 
be signs of consolidation, while lower down the note is exaggerated 
or vesiculotympanitic over the unaffected mid-region of the lung, and 
over the base there will also be marked dulness. This lower area of 



DISEASES OF TEE LUNGS. 625 

dulness should not be regarded as a sign of consolidation. It is really 
due to the accumulation of a small amount of serous effusion in the 
lower part of the pleural cavity as a result of the complicating pleurisy. 

Auscultation will in this stage give bronchial voice and breath- 
ing over the affected area of the lung; over the unaffected lung the 
respiratory murmur, especially the inspiratory sound, is harsh. This 
harsh inspiratory sound is quite common in children, and is fre- 
quently mistaken for bronchial breathing. Bronchial breathing is 
tubular in quality on inspiration and expiration. In this stage, if 
the upper lobe of the lung is also involved and there is some pleuritic 
effusion in the chest, the respiratory murmur may be much dimin- 
ished over the lower region of the chest behind. 

The voice also has a tubular or bronchial quality over the con- 
solidated area. The intensity of the voice may be diminished over 
the lower portion of the chest if pleuritic effusion is present with 
consolidation of the upper lobe. Pleuritic rales may in this stage 
be heard over the whole side of the chest. 

Third Stage. — The third stage, that of resolution, is sometimes 
delayed, some days elapsing after the crisis before appearance of the 
sign pathognomonic of this stage — the so-called rale redux. This 
rale has the same qualities as that heard in adults at the same stage. 
In children it is sometimes present for only a short time, and is not 
heard over any considerable area of the lung. I have known the 
temperature to be subnormal for two days or more before its appear- 
ance. The other sign, which is less important, is a distinct diminu- 
tion of the fremitus until it reaches the normal intensity over the 
affected area of lung. The percussion-note becomes less dull, assum- 
ing the vesiculotympanitic quality. Repeated auscultation reveals, 
in addition to the rale redux, a gradual return of the voice and breath- 
ing to the normal, which sometimes takes weeks. The tubular quality 
of the voice and breathing over the affected area of lung may per- 
sist long into convalescence. It is probably not caused by any actual 
persistence of consolidation, but by a continued hyperaemia of the 
lung. The lung under these conditions is denser and conducts sounds 
from the bronchi with greater intensity than the healthy lung. If 
pleurisy has been present to any extent, there may, after the disap- 
pearance of the signs of consolidation, be signs of dry pleurisy or 
those of effusion. 

Pneumonia of an Unusually Shorf Course. — LeubeandWeil have 
observed in the adult typical pneumonia of the fibrinous variety and 
of very short duration. Some el' these cases exhibit the chill, fever, 
pain, and crisis, with other signs of physical involvement o\' the lung, 
within twenty-four to thirty-six hours. Jiirgensen has recorded 
short lethal pneumonias o( the fibrinous variety in the adult. The 

40 



626 



DISEASES OF THE RESPIRATORY SYSTEM, 



cases of Levy and Jiirgensen were fatal within twenty-four to thirty- 
six hours. I have never observed such cases of fibrinous pneumonia 
in children, but have seen lobar pneumonia with a history of short 
duration (Fig. 130). In cases running a very short course there is 
doubt as to whether the signs obtained over the chest may not have 
been connected with a preceding attack. Henoch has, however, met 
a few cases which ran a rapidly fatal course, with the whole symp- 
tomatology of lobar pneumonia, including physical signs, in forty- 
eight hours. 

Fig. 130. 



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Lobar pneumonia, midregion of the right lung ; crisis on the fourth day of disease. Boy, 
seven years of age. (Author's case.) 



Complications. — Among the complications of fibrinous pneumonia 
in infants and children are otitis, pleurisy, pericarditis, endocarditis, 
empyema, and meningitis, arthritis and osteomyelitis and peritonitis. 
Gastro-enteritis is quite a common complication. 

Otitis. — Otitis is common, its frequency varies in different epi- 
demics. It affects younger children and infants more frequently 
than older subjects. The temperature in these cases becomes more 
markedly remittent and remains higher for a greater length of time 
than in the uncomplicated cases. I have frequently suspected otitis 
from a study of the temperature-curve, which is not, however, an 



DISEASES OE THE LUNGS. 



627 



altogether reliable guide. Suppuration in the pleura will give a 
similar curve. Therefore, in a concrete case of persistent high tem- 
perature-curve with morning remissions, otitis should be suspected, 
but not positively diagnosed without careful exclusion of other com- 
plications and otoscopic examination. Otitis as such does not seem 
to give any striking symptoms of pain. The patient may without 
warning present perforation of the drum of one or both ears and a 
purulent discharge. The temperature will then fall to the normal. 
Diplococcus pneumoniae has been found by a number of observers in 
this discharge. The otitis is of a benign nature. 

Meningitis. — Meningitis occurs in a number of cases, and may 
usher in the disease. I have seen it persist for weeks. The prog- 



Fig. 131. 




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Lobar pneumonia, lower lobe, left lung ; complicating pleurisy : temperature falling 
gradually to tbe normal. Leucocyte count indicated. Boy, five years of age. 



nosis in this form of meningitis, if it assumes the cerebrospinal type, 
is graver than when it occurs as a primary disease, with the intra- 
cellular diplococcus of Weichselbaum as a causative factor. Xetter 
seems to have met a larger number of cases of the pneumococcus 
form of meningitis than any other author. The cases of meningitis 
complicating pneumonia may be due to either the pneumococcus, 
streptococcus or meningococcus. The cerebrospinal symptoms, or 
meningism, as it is called, seen at the outset or at the crisis in some 
cases of pneumonia do not last for any great length of time, and d»> 
not present the true symptoms of meningitis. In other cases it is 
sometimes impossible to differentiate between simple cerebral symp- 
toms or the so-called meningism and ihe existence o( a complicating 
meningitis. Even after close study a lumbar puncture may be nec- 
essary to clear up the diagnosis. 

Pleurisy and Empyema,- Many cases of fibrinous pneumonia 



628 DISEASES OF TEE EESPIBATOEY SYSTEM. 

show a dry pleurisy sometimes persisting for a long time after con- 
valescence. Of greater moment are the cases of pleurisy with effu- 
sion, which follow a lobar pneumonia. In these, there is always the 
danger that the exudate may eventuate in an empyema. The dura- 
tion of the exudate is no guide in determining whether it is of a 
serous or a purulent nature. It is frequently found that after a 
pneumonia has run its course the temperature remains raised a degree 
or more toward evening. Such a rise in temperature may, in the 
absence of signs of fluid, indicate a dry plastic pleurisy (Fig. 131). 
On the other hand, if there are signs of fluid and the temperature- 
curve shows irregularities of rise, empyema may be present. I have 
seen empyema without any rise of temperature in infants who showed 
the physical signs of fluid in the chest. These points will be more 
fully discussed in considering Empyema. 

Pericarditis. — I have seen pericarditis in infants who died of a 
fibrinous pneumonia, but the diagnosis was not made during life. 
Yon Jaksch notes such cases. In older children, pericarditis is a 
complication found in cases of fibrinous pneumonia which have simul- 
taneously developed empyema. Such cases are very uncommon. In 
the form of pericarditis which I have seen in infants, the quantity of 
effusion has not been sufficiently great to enable a diagnosis to be 
made with certainty, and the rales in the lung obscured the friction- 
sounds in the pericardium if they were present. Purulent pericar- 
ditis in these subjects is very fatal under such conditions. In older 
children I have seen pneumonia combined with a fibrinous pericar- 
ditis pure and simple, without fatal issue. 

Prognosis. — The prognosis of lobar pneumonia varies within cer- 
tain limits. Text-books give statistics taken from hospital cases, 
notably the most unfavorable material. Henoch gives the mortality 
of his cases at 5 per cent. ; Baginsky, at 8 per cent. ; Holt, at 12 per 
cent. ; my own hospital cases during the past year showed a mortality 
of 8 per cent. On the other hand, in private practice death from an 
acute fibrinous pneumonia rarely occurs in a child previously healthy 
and living in good surroundings. 

The mortality is influenced by the season of the year, being greater 
f r< >m December to February, and by the presence of an epidemic. If 
pneumonia is prevalent during an epidemic of influenza, the mor- 
tality will increase. Pericarditis or complicating empyema influence 
the death-rate. The previous condition of the patient, the mode of 
feeding (whether by the breast or the bottle), and a rachitic or ma- 
rantic condition, affect the prognosis. The age of the patient is also 
an important factor. Infants under one year of age are in greater 
danger than older ones. The prognosis is best from the third to the 
tenth vear. The younger the bottle-fed babv. the more serious the 



DISEASES OF TEE LUNGS. 629 

complication of empyema. In making a prognosis in any concrete 
case, the physician should be gnided by the extent of lung involve- 
ment and the general condition of the circulation. If one lobe alone 
is involved and there is an absence of bronchitis in the unaffected 
lung, the outlook is good. If the heart action is good and there is an 
absence of cyanosis, recovery can be predicted even if the temperature 
be high. If, on the other hand, the lysis or crisis is delayed and the 
dulness or flatness involves a whole side of the chest, in the presence 
of signs of a weak heart the prognosis should be made with caution. 

Meningitis is grave. I have seen cases of meningococcus menin- 
gitis which complicated pneumonia recover, but pneumococcus and 
streptococcus meningitis are fatal. Pericarditis in young infants 
and children is a complication invariably fatal. Where facilities 
exist, a leucocyte-count should be taken every second day, accom- 
panied by a differential count of leucocytes. A very low leucocyte- 
count, with marked signs of pneumonia and a high temperature, is a 
grave prognostic sign, though such cases may recover. On the other 
hand, a continued high leucocyte-count, as has been pointed out, may 
be present with extensive inflammation of both lungs, and death 
may ensue. 

Diagnosis. — The diagnosis of lobar pneumonia in infancy and 
childhood ordinarily presents few difficulties, but is not easily made 
if in addition to the pneumonia there is an effusion in the chest. The 
diagnosis should never be made early in the disease without positive 
signs. 

The crepitant rale sometimes escapes observation. The physician 
should then wait for the appearance of dulness or bronchial voice and 
breathing before arriving at a conclusion as to the presence or absence 
of consolidation. Cases of influenza with a harassing cough are fre- 
quently diagnosed as central pneumonia. A pneumonia which is 
central will give physical signs when the consolidated area approaches 
the pleura. If after the time set for the crisis or lysis, the tempera- 
ture persists and becomes remittent, careful examination should be 
made for evidences of fluid in the chest. The nature of the fluid 
should be determined by exploration with the aspirating needle, if the 
fever does not subside anel if the dyspnoea increases. A ehesl effu- 
sion in infants and children is apt to be purulent. 

The cerebral eases present difficulties of diagnosis. Convulsions, 
delirium and rigidity of the neck, accompanied by high fever and a 
cough, with increase of the pulse-rate and the number oi' respirations, 
indicate the necessity of making a very careful examination of the 
chest. 

Incases which begin with a lobar pneumonia, typhoid fever may 
be suspected if, after the first days of illness, a roseola or an enlarge- 



630 DISEASES OF THE JRESPIEATOEY SYSTEM. 

ment of the spleen develops with a continuance or gradual rise of 
temperature. In such cases the presence of an epidemic of typhoid 
fever and the Widal hlood reaction will be of service in clearing up 
the diagnosis. 

Treatment. — The treatment of lobar pneumonia is pre-eminently 
expectant. The disease is self limited, and complications cannot be 
prevented. The temperature should be treated within certain limits, 
and the heart and the strength of the patient supported. The tem- 
perature should be treated not with a view to its actual reduction, 
but in order to mitigate its ill effects. Infants and children will be 
less affected by a temperature of 103° F. (39.4° C.) during a pneu- 
monia than by the same temperature in typhoid fever. The toxaemia 
of pneumonia is of a more benign character. 

Hydrotherapy. — Sponging is efficient in cases in which the tem- 
perature does not generally range above 104° or 104.5° F. (40° C). 
The younger the infant the less energetic need it be, for a tempera- 
ture of 104.5° F. (40° C.) is not high for an infant under two years 
of age. I content myself with sponging the body with water at 80° 
F. (26.6° C), to which some alcohol has been added. If the tem- 
perature remits a degree or more during the twenty-four hours, there 
will be less need of sponging. The temperature should never be 
taken more often than every three hours. If it is above 103.5° F. 
(39.7° C), the patient is sponged for fifteen minutes and then given 
absolute rest for three hours. Frequent sponging is pernicious. 
Some infants when sponged with water at 80° F. (26.6° C.) become 
eyanosed, with rapid and thready pulse. With these patients a warm 
bath at a temperature of 105°' to 107° F. (40.5° to 41.6° C.) is 
stimulating. It supports the strength and certainly lessens the ill 
effects of the temperature, although it may not reduce it palpably. 
I do not use the full cold bath in the treatment of lobar pneumonia in 
infants and children. If the temperature reaches 105°-106° F. 
(40.5°-41.1° C), a full bath of the temperature of 85°-90° F. 
(29.4°-32.2° C.) or higher may be given, certainly never lower. 

One of the most useful methods of hydrotherapy in the treatment 
of pneumonia in young infants is the so-called chest compress. These 
compresses renewed every hour will cause the restlessness to diminish, 
the heart action to improve, and the patient to fall into a quiet slum- 
ber. The actual reduction of temperature is not so marked as the 
favorable effect on the general condition of the patient. The appli- 
cation of compresses is discontinued if the temperature falls below 
103° F. (39.4° C). 

Medicinal Treatment. — The heart action if good needs no atten- 
tion. At most, a limited amount of alcohol in form of wine or 
whiskey is administered. Infants may receive half a drachm (2.0) 



DISEASES OF THE LUNGS. K'A 

every few hours; older children, a drachm (4.0 J. Alcohol should 
not be given as a routine remedy. If the temperature is high, neces- 
sitating hydrotherapy, and the pulse is above 120, alcohol should be 
given. If the pulse is high, 150-160, a few minims of the tincture 
of digitalis may be given to older children. Younger children rarely 
need more than half a minim every two or three hours. If the puke- 
rate is reduced after the administration of digitalis, the drug should 
be discontinued before the pulse drops below 100. There is no doubt 
that its effect is more cumulative in some subjects than in others. 

Strychnine is of value in the treatment of pneumonia, not so 
much in the cases with rapid as in those with slow and irregular 
pulse. Infants will bear grain %oo to Yiso (0.0003 to 0.0004) every 
three hours, for days. 

Caffeine is of great value in the treatment of irregularities of the 
heart which indicate a myoearditic toxaemia. The pain is the result 
of a pleuritic process. 

The local application of iodine or mustard paper is an efficient 
counter-irritant. If the cough is troublesome, codeine in moderate 
dosage is the most useful remedy. 

I do not use morphine with infants and children. In young 
infants the milder preparations of opium, such as camphorated tinc- 
ture or the wine, are more useful. Four minims (0.25) of the cam- 
phorated tincture of opium every two or three hours will be found 
efficient in children under two years of age. To older children a small 
dose of codeia may be given several times daily if needed. The aim 
is to alleviate, not abolish, the pain and cough. 

The bowels should be evacuated daily; for this purpose hydrarg. 
cum creta is one of the best remedies. Grain v (0.3) may be given. 
Infants should receive an enema daily. If gastro-enteric disturb- 
ances are present, milk should be discontinued, broths substituted and 
the same procedure followed as in primary gastro-enteritis. 

Tympanites is sometimes troublesome, especially in young chil- 
dren. The best remedy is a high enema twice daily of salt solution, 
to which one or two teaspoonfuls of peppermint-water have been 
added. The passage of a soft catheter is not effective, nor are the 
turpentine stupes of any value. Milk should be eliminated tempo- 
rarily from the diet. 

The delirium, sometimes amounting to an acute mania, which 
appears just before the crisis in some eases, is best controlled by 
rectal administration of bromide o( potassium and chloral hydrate. 
I have sometimes been forced to keep the patient under the influence 
of these drugs for a few days. The post-pneumonic melancholia 
seen in children is best treated by the administration o( strychnine 
and the enforcement o( perfect quiet. 



632 DISEASES OF THE BESPIBATOBY SYSTEM. 

Should signs of extreme cardiac weakness set in with threatening 
oedema of the lung and paralysis of the right ventricle, nitroglycerin 
is of great value. Infants will bear grain /4oo (0.0003) every three 
hours. If in these cases cyanosis is present, oxygen is administered, 
preferably that containing 20 per cent, of nitrous oxide. It is given 
to infants, every half hour for five or ten minutes at a time by means 
of a cone. 

Hygiene. — The patient should be isolated if possible. The room 
should be ventilated and its temperature kept at 6S C -72 C F. (20 c - 
22.2° C). 

The sputum should be received in pieces of gauze, which are 
burned. The mouth and teeth should be cleansed twice daily with 
a piece of soft linen and a solution of boric acid. In the intervals 
between feedings the tongue is kept moist by frequent draughts of 
water. 

Bronchopneumonia ( Catarrhal Pneumonia, Lobular Pneumonia). 
— Bronchopneumonia is the prevalent type of pneumonia occurring 
before the fifth year, but many cases of lobar fibrinous pneumonia 
are seen during infancy and early childhood. 

Occurrence. — Bronchopneumonia occurs both as a primary and a 
secondary disease. As a primary disease it is most frequent during 
the first two years of life. Of 605 of my cases of bronchopneumonia, 
the incidence in regard to age was as follows : 

Cases. 

One to three months 32 

Three to six months 6S 

Six to twelve months 207 

One to two years 298 

These figures correspond within certain limits to those of other 
observers, although Holt places the greatest frequency between the 
sixth and the twelfth months. 

Sex. — Of the 605 cases. 322 were males — a statement correspond- 
ing to that of Jurgensen in regard to lobar pneumonia. 

Season. — The greatest frequency is during the winter months, 
when there are epidemics of influenza during which many primary 
and secondary cases of bronchopneumonia occur. 

Surroundings. — The herding together of the poor certainly has 
a tendency to increase the prevalence of bronchopneumonia among 
them. If we believe in the epidemiological aspects of pneumonia, it 
is easy to account for the greater frequency of the disease among the 
poor: the greater number of their children are rachitic, syphilitic, 
marantic, and ill-fed, and thus have increased susceptibility to in- 
fection. 

Secondary bronchopneumonia occurs as a complication in the 



DISEASES OF THE LUNGS. 633 

exanthemata (measles, scarlet fever, typhoid fever), diphtheria, per- 
tussis, and influenza. By far the greater number of ease- occur as 
a sequence of ordinary bronchitis. 

Etiology and Bacteriology. — Weichselbaum first demonstrated that 
the pneumococcus of Frankel could cause primary bronchopneumonia. 
His results have been confirmed by Cornil, Babes, and Neumann, the 
latter of whom found the pneumococcus in cases of primary broncho- 
pneumonia. Quesiner and Neumann found the pneumococcus in the 
sputum of children suffering from bronchopneumonia. 

The secondary form of bronchopneumonia may be caused by 
streptococci (Northrup and Prudden), which invade the lung-tissue 
from the trachea, as in diphtheria. Guarnieri also found strepto- 
cocci in the lungs of children dying with bronchopneumonia after 
measles. On the other hand, these secondary types of bronchopneu- 
monia may also be caused by the pneumococcus of Frankel, which is 
an etiological factor in the primary type of the disease. This has 
been shown in the work of JSTetter on the subject, and confirmed by 
Banti, Strelitz, and Baginsky. In diphtheria the Klebs-Loffler ba- 
cillus may be found in the lung areas of secondary bronchopneumonia 
(Babes, Frosch, Baginsky). The Eberth bacillus has been found in 
areas of bronchopneumonia complicating typhoid fever (Polyniere). 

Morbid Anatomy. — The essential lesion in bronchopneumonia is 
an inflammation of the walls of the bronchi and of the air-spaces sur- 
rounding the inflamed bronchi (Delafield). The walls of the bronchi 
are thickened and infiltrated with small round cells ; those of the 
alveoli of the lung are thickened and their cavities filled with fibrin, 
pus, epithelial cells, and new connective tissue. The smaller bronchi 
are dilated and contain pus, their walls being infiltrated. The in- 
flammation may also be conveyed from the bronchi to the paren- 
chyma of the lung by aspiration of secretion (Ziegler). In the latter 
case the smaller bronchi are occluded, collapse of the lung follows 
(atelectasis), and a pneumonia thus results. On section there are 
seen grayish-red, gray, or yellowish-gray areas of varying consistency. 
which correspond to a cut bronchus and its surrounding peribron- 
chitic pneumonia. 

If the areas are croupous, they have a more granular appearance. 
Small areas of this form of pneumonia may coalesce, and thus whole 
lobules of the lung may be consolidated. These larger areas may be 
separated by lung-tissue which contains air, or a whole lobe may be- 
come consolidated, as in lobar pneumonia. The exudate found in the 
affected alveoli is at first composed of desquamated swollen epithelial 
cells, and later of leucocytes. If (he exudate has a more fluid char- 
acter, it is called catarrhal. It then contains more serum than fibrin. 
If the fibrin is in excess, the exudate has greater consistency, resent- 






634 DISEASES OF THE EESPIBATORY SYSTEM. 

bling that of lobar pneumonia, and is then called croupous. The 
catarrhal and croupous forms of exudate may both exist in a lung 
affected with bronchopneumonia. Blood-cells may predominate in 
the exudate, so that the lung may on section have a hemorrhagic 
appearance. This is apt to be the case in streptococcus inflammation 
and also if foul fluids have been aspirated. 

The mucous membrane of the bronchi is the seat of catarrhal 
inflammation. 

There is inflammation of the pleura to a varying degree. 

The bronchial and mediastinal lymph-nodes may be enlarged. 
There is oedema of the lung tissue which is not inflamed. Broncho- 
pneumonia may result in resolution and restoration to the normal. 
Suppuration and formation of abscess with destruction of lung tissue, 
or gangrene of the lung, may result in rare cases. 

Persistent bronchopneumonia in children leads to induration of 
the lung. There is an increase of the connective tissue of the alveolar 
septa, of the walls of the smaller and larger bronchi, and also of the 
walls of the peribronchial vascular tissue. The lung on section is 
seen to be studded with fibrous nodules, or a whole lobule or lobe may 
be converted into connective tissue. 

Symptoms. — Bronchopneumonia is divided clinically into several 
distinct types. In newly born and very young infants the disease 
may set in insidiously. The infant is born in normal condition; 
after some little exposure it develops slight snuffles and a slight cough. 
Dyspnoea then appears. All this may occur within the first eight 
days after birth. The cough becomes more harassing and the dyspnoea 
more marked. Slight cyanosis supervenes after a time. The infant 
is restless and does not sleep, the cyanosis becoming more marked and 
constant. The infant may have frequent convulsions. The dyspnoea 
finally becomes so marked as to cause distinct drawing inward of the 
lower part of the chest-wall with each inspiration. In these cases 
there is little or no temperature ; in that respect they resemble cases 
of bronchopneumonia in extremely old people. 

The temperature may be slightly subnormal even when the infant 
is mortally ill with a disseminated bronchopneumonia. The cough 
may not be marked. These cases should be differentiated from those 
occurring in infants born with an atelectatic condition of the lungs. 
In the class of cases under consideration, atelectasis develops as a 
sequence of the bronchitis and bronchopneumonia. The movements 
are greenish, containing undigested curds. The infants may finally 
develop enteritis. The course of the disease is in these cases very 
acute. The infant either rapidly grows worse or begins to improve 
immediately. The former course is, however, the rule in this verv 
dangerous and insidious form of bronchopneumonia. If the infant 



DISEASES OF THE LUNGS. 635 

does not improve, the cyanosis becomes more marked, as does also the 
dyspnoea; the respirations increase to more than 80 a minute, the 
pulse becomes very rapid, and the heart feeble; the infant lies in a 
soporose state; the end may supervene with tympanites, convulsions, 
and oedema of the lung. This form of bronchopneumonia is very fre- 
quently overlooked at the outset and mistaken for a simple bronchitis. 

Another form of bronchopneumonia in infancy begins as a simple 
bronchitis, and may be treated as such for days. Finally, posteriorly 
in both lungs there are found the fine crepitations which give warning 
of the presence of bronchopneumonic processes. Bronchopneumonia 
of this variety runs its course without temperature. It occurs in 
rachitic or weakly infants and children, or follows a mild attack of 
influenza. The attacks of coughing are especially troublesome, and 
are frequently followed by vomiting of the contents of the stomach. 
The movements are loose, and show greenish particles and undigested 
white flaky masses. The dyspnoea is constant and characteristic, and 
if the patient is out of bed, grows more marked toward the late after- 
noon. The alse nasi are dilated. The temperature rarely rises above 
101° F. (38.3° C), and is generally 100° F. (37.2° C.) or even 
lower. The cough may persist for weeks after the subsidence of the 
acute symptoms, being especially marked at night. 

A more common form of bronchopneumonia in infancy begins 
as a simple bronchitis, which may last for a few clays, when, without 
warning, the infant has a chill followed by a rise of temperature, the 
case having suddenly developed into a full bronchopneumonia. In a 
six weeks' old infant with disseminated patches of pneumonia, the 
chill was so severe as to cause extravasations of blood underneath the 
surface, with markings resembling those seen in marbling of the sur- 
face. In another case the chill was so severe that an immediate 
fatal issue was feared. In that bronchopneumonia sometimes begins 
with a chill, it resembles a lobar process. 

The most common type of bronchopneumonia may begin with a 
rise of temperature preceded by vomiting. The harassing cough is 
present from the outset, causing the patients to cry with pain at each 
attack. There is no sputum, but in very young infants a frothy 
mucus may in the later stages of the disease collect about the lips. 
The dyspnoea is marked. The alse nasi are dilated at each inspira- 
tory effort. The peripneumonia groove is retracted and in very 
severe dyspnoea the suprasternal region may also be depressed at each 
inspiration. Very frequently the dyspnoea will resemble that due to 
laryngeal stenosis. There are, however, none o\' the si^ns o\ laryn- 
geal obstruction, such as laryngeal breathing. 

Fever.- Fever is always present in infants and children, except 
in the classes of cases above noted. It may reach 106° V. ( H.l° 



636 



DISEASES OF THE HESPIBATORY SYSTEM. 



C), and is as a rule remittent. It may fall gradually to the normal, 
and in the favorable eases may reach the subnormal and remain there 
for a few days. The course of the fever is, however, not an indica- 
tion of the severity of the disease. Fatal bronchopneumonia some- 
times shows a steady decline in the temperature toward the approach 
of the fatal issue. In other cases the temperature may drop to the 
normal, remain there a few hours or a day, and then rise sharply to 
104° F. (40° C.) or higher, thus indicating that a new area of the 
lung has been invaded by the disease (Fig. 132). Such rises of 
temperature after a fall to the normal are of grave import if they 
occur in an infant acutely ill with a process which has been severe 
for days. They show a tendency of the process to spread, and in 
young weakly infants such an extension of the process is apt to be 



Fig. 132. 


J^ Jan. 4 5 6 7 8 9 10 j 


3 4 5 6 7 8 9 


HOUR 369 12 3 6 | 9 12 369 12 369 12 369 12 369 12 36 9 12 369 12 369 12 369 12 369 12 369 12 369 12 3 6 1 9 |I2 

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pulse £ s 212 = 1 £ IS SIS 122 IS 2 2 


RESP. 2S3 gS3 ?s^25? : S?g S3 SSggggg S ggggg S § 3 5 3 g§ 



Fatal bronchopneumonia ; reinvasion of the lung on the fifth day. Infant, six months old. 

fatal. A drop by lysis to a normal temperature which continues for 
a few days, and is followed by a slight gradual rise with subsequent 
remissions to the normal, is also common, and may indicate a return 
of the bronchopneumonia process, or a pleuritic effusion of a puru- 
lent character. The physician should be on the alert for an effusion 
in the cases which have run an irregular or remittent temperature 
for a period of more than two weeks. I have, however, operated upon 
cases of empyema following bronchopneumonia in infants, in which 
the temperature-curve was normal for days, and then showed occa- 
sional rises to 101 c or 102° F. (38.3° or 38.8° C). 

Pulse. — The pulse is as a rule rapid. It is difficult in infants to 
estimate its exact character. It is, however, always possible to dis- 
tinguish the abnormally weak and thready pulse even in the youngest 
infant. The rapidity of the pulse varies widely even in the favorable 
cases. Its ratio to the respiration (the pulse-respiration ratio) is, as 
a rule, maintained in favorable cases. Even if it be so much dis- 
torted as to present the ratio of 1 to 2, the patient may make a good 



DISEASES OF TEE LUNGS. 



637 



recovery. The character of the pulse and respiration should there- 
fore be judged in connection with other signs of decreasing heart 
power, such as abnormal pallor, coldness of the surface, and cyanosis, 
however slight. In artificially fed infants who are above the average 
weight, the beginning of cardiac weakness is indicated by an abnormal 
pallor of the face and slight cyanosis of the lips. 

Sputum. — In young infants there is no sputum, nor is it probable 
that in uncomplicated cases of bronchopneumonia the younger infants 
cough up and swallow sputum, as is generally supposed. At most, 
there is after severe attacks of coughing a collection about the lips of 
frothy mucus, probably coming from the trachea. 

Fig. 133. 



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Ordinary type of bronchopneumonia. Recovery. Female child, one year and six 

months of age. 



Gastro-enteric Tract. — The symptoms referable to the stomach 
and intestine are of great importance in severe bronchopneumonia of 
the primary type. Even up to the second year of life tympanites 
sets in very early. It may mislead the physician into thinking that 
peritonitis might be present. It is especially apt to set in with 
rachitic and weakly, artificially fed infants. It is appears late in 
a very sick infant, it is a symptom of grave import, and may some- 
times cause the fatal issue. In some cases the pre-agonal distention 
is very great, and so far as can be judged painful. Seme infants 
begin to vomit from the outset of the pneumonia. The vomiting may 
occur once or twice in the twenty-four hours, or may be incessant. 
With the vomiting there may be the passage of greenish stools or a 
fully developed enteritis of severe type. So severe is the enteritis in 
some cases as to cause the death of a patienl suffering from pneu- 
monia of only moderate severity. This form of the disease dor- not 
occur exclusively in the summer months, bu1 is more prevalent at 
thai time. 



638 DISEASES OF THE EESPIEATOEY SYSTEM. 

Cerebral Symptoms, — The infant is in some eases stupid from 
the outset of the disease. Older children may have slight convulsive 
twitehings of the muscles of the face and extremities. In some cases 
in children in the third year there may be complete unconsciousness 
and symptoms simulating those of meningitis, such as rigidity of the 
muscles of the neck. I have seen the cerebral symptoms persist for 
weeks in young infants who made complete recoveries. In other 
cases, the bronchopneumonia may partly resolve, and still there may 
be a continuance of the cerebral symptoms or even an exacerbation 
of them. In these cases the possibility of the presence of otitis or 
mastoid inflammation should be seriously considered. 

The secondary form of bronchopneumonia may complicate the 
exanthemata — measles, scarlet fever, varicella, typhoid fever, per- 
tussis, influenza, and diphtheria, and also gastro-enteritis or any form 
of infection, such as that of septic wounds or osteomyelitis. 

Pertussis. — The symptoms of bronchopneumonia which compli- 
cates pertussis are of an unequivocal character. A febrile movement 
may be present with a simple bronchitis. If bronchopneumonia is 
imminent or present, the fever is marked and constant, and may 
reach 106 = F. (41.1 z C). The dyspnoea is very marked, but the 
cough may not be increased. In certain forms of pertussis without 
complications there is a slight constant dyspnoea, which is due to the 
disease. If bronchopneumonia is a complication the dyspnoea is more 
decided, the number of respirations three or four times the normal, 
and the pulse-rate increased. There is marked cyanosis. There may 
be all the symptoms of a severe bronchopneumonia, such as tympa- 
nites, vomiting, and green diarrhoeal stools. The bronchopneumonia 
is. as a rule, of the disseminated type, with areas of consolidation of 
greater or lesser extent in both lungs. The infants are much more 
ill than they would be with a primary process of the same extent. 
A bronchopneumonia of this kind can be diagnosed if upon exami- 
nation there are, in addition to the physical signs of bronchitis, fine 
crepitations over the different parts of the chest, especially over the 
lower lobes of both lungs posteriorly. There may also be dulness 
with bronchophony and bronchial breathing over small areas, either 
in the upper or lower lobes of the lung on one or both sides. 

The bronchopneumonia of pertussis may supervene at any period 
of the disease, and is not the result of exposure. On the contrary, it 
may occur in infants and children who have been most carefully pro- 
tected from exposure. It is the result of the type of disease — a 
mixed infection. The pertussis probably makes the lung more liable 
to disease in some subjects than in others. The bronchopneumonia 
is a grave complication, and is^ very fatal. It may cause complica- 
tions, such as pleurisy of a serous or purulent nature, and often opens 



DISEASES OF TEE LUNGS. 639 

the way for invasion of the lung by tuberculosis. It may run a 
chronic course (persistent pneumonia) and reduce the patient to a 
very weak state. The patient will then develop consolidation of a 
whole lobe of the lung which will take weeks to clear up. 

Measles. — Bronchopneumonia complicating measles supervenes, 
as a rule, in the stage of eruption, and is a very serious complication. 
Its presence may be suspected if, on examination of the chest, there 
are found, in addition to the rales of bronchitis, very fine crepitant 
rales over areas disseminated through both lungs. This complication 
also causes a febrile movement after the fading of the eruption and 
repeated severe chills with every new area of the lung involved. 
There are severe cough and dyspnoea. The pulse may reach 180 to 
190, and the respirations 90, but the patient may recover even if the 
signs of cardiac weakness, such as cyanosis, are marked. The patient 
is stupid, does not take food or notice his surroundings. Sometimes 
there may be other signs, such as hemorrhages into the eruption (so- 
called hemorrhagic measles), indicating that the process is one in 
which there is a mixed infection. There may be a complication of 
serous or seropurulent pleurisy. 

Typhoid Fever. — Bronchopneumonia complicating typhoid fever 
does not, as a rule, give very striking features apart from those be- 
longing to the latter disease. It seems to be of a mild and insidious 
character. The bronchopneumonia of typhoid fever is apt to mask 
the typhoid if it appears at the outset of the disease. There is then 
a typhoid beginning as a pneumonia. The area of bronchopneumonia 
is well localized. It may be a small area in the upper or mid-region 
of the lung. The febrile curve in these cases may range quite high 
at the outset and thus mislead the physician. The process persists 
for weeks, sometimes as long as five weeks. The lung is slow in 
clearing up. The signs of dulness, bronchial voice and breathing may 
persist into convalescence. In other cases the pneumonia may super- 
vene in the course of the disease. It can then be detected only if 
the cough is harassing and the dyspneca marked. In delirious pa- 
tients the pneumonia can only be discovered by repeated and constant 
examination of the chest. These cases are not so apt to develop 
pleurisy of a serous or purulent nature as the pneumonia complicat- 
ing measles or scarlet fever. 

Varicella. — Varicella is only rarely complicated by bronchopneu- 
monia. In this disease also the pneumonia runs a protracted course. 
but is less serious in its outcome than in the other exanthemata, li 
occurs in the severer forms of varicella in which the eruption is com- 
plicated with ahseessos or necrosis o( the skin (mixed infection). 

Scarlet Fever. — Scarlet fever is not so frequently complicated by 
bronchopneumonia as measles, but when il doi>s occur the broncho- 



640 DISEASES OF THE EESPIEATOEY SYSTEM. 

pneumonia is of a very severe type. It occurs in the septic forms of 
scarlet fever, and may appear early in the disease, on the fading of 
the eruption. Scarlet fever complicated by bronchopneumonia is 
frequently followed by pleurisy of a purulent nature. 

Diphtheria. — The bronchopneumonia which complicates diph- 
theria has been carefully studied by Xorthrup and Prudden. It is 
the result of a streptococcic invasion of the lung or an invasion by 
the Klebs-Loffler bacillus. As a rule, however, it is a mixed infec- 
tion, as was pointed out by Xorthrup and Prudden. The laryngeal 
form of diphtheria frequently proves fatal through this complication. 

Diarrhoeal Conditions. — Of special interest is the bronchopneu- 
monia which complicates chronic or subacute diarrhoeal conditions. 
This form, which is of a distinctly septic type, is caused by infection 
of the lung by streptococci, which invade the general circulation 
through erosions in the mucous membrane of the gut (Booker, Czerny. 
Fischl). It is not always due. as was formerly supposed, to keeping 
the infant in the recumbent posture, nor does it occur in hospital 
practice alone, but is frequently seen in private practice in infants in 
unhygienic surroundings. It is of the persistent type, and runs its 
course with a daily high or low febrile curve, and results in areas of 
consolidation, which sometimes involve a whole lobe of a lung. This 
form of pneumonia is one of the fatal complications of the subacute 
intestinal catarrhs. 

Some infants, after one attack of bronchopneumonia, have re- 
peated or recurrent attacks on the least exposure (Fig. 134), in some 
cases developing catarrhal croup. In other cases, there develops an 
emphysematous condition of the lung, in which the least exposure or 
change in the atmosphere will cause an asthmatic attack. 

Course, Termination, and Complications. — Bronchopneumonia may 
terminate in complete recovery and restoration of the lung to the 
normal, or may prove fatal. The mortality varies at different times 
and with the environment. The prognosis in marantic infants, and 
also in bottle-fed infants, is very bad. Rachitic infants have bron- 
chopneumonia with a very protracted course (Pig. 135). The forms 
which complicate measles, pertussis, scarlet fever, and influenza are 
very fatal. Abscess or gangrene of the lung may be a complication. 
In some forms of otitis the symptoms may very closely simulate those 
of tuberculous meningitis. Otitis prolongs the disease and frequently 
misleads the physician. Especially trying are the forms of broncho- 
pneumonia of very limited extent in one or both lungs, in which there 
is a protracted, remittent or intermittent fever-curve. Serous pleu- 
risy and empyema are very common complications. Their presence 
may be suspected if the disease runs a course protracted beyond two 
weeks, and if signs, such as dulness. flatness, and bronchophony, per- 
sist and become more marked over the whole side of the chest. 



DISEASES OF THE LUNGS. 



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41 



642 DISEASES OF THE BESPIJRATOEY SYSTEM. 

Meningitis. — Meningitis may complicate the disease. Care should 
be taken not to confound cerebral symptoms with true meningitis. 

Pericarditis. — Pericarditis complicating bronchopneumonia is 
apt to be purulent, and is rarely diagnosed during life. I have seen 
cases in which during life repeated examinations failed to reveal 
positive signs of effusion into the pericardium, but in which purulent 
pericarditis was found at autopsy. This is frequently true of cases 
in which the effusion is limited (30-50 grammes). If bronchopneu- 
monia occurs in the left lung with consolidation anteriorly and some 
pleural effusion, it is almost impossible to diagnose moderate peri- 
cardial effusion. The complication is very fatal. 

Osteomyelitis. — Pfisterer has recently published a number of cases 
of pneumococcus osteomyelitis and metastases occurring by way of 
the blood or lymph-stream. In some cases the arthritis may precede 
the pneumonia; in others, may follow it. The portals of infection 
include the tonsil, among others the mouth or nose, the ear or peri- 
toneum. Traumatism may be a predisposing factor, better found 
3 of arthritis in 1218 cases of pneumonia. It is therefore rare as 
compared to other complications of pneumonia, such as otitis or men- 
ingitis. I have seen one case in a newborn infant, the subject of 
congenital syphilis, with bronchopneumonia of a syphilitic character. 
In this case the hip-joint was the seat of pneumococcus suppuration. 
I have since seen a number of cases of pneumococcus arthritis in in- 
fants. As a rule, the larger joints, the shoulder or knee, are affected. 
It is generally monarticular, but may be polyarticular. The symptoms 
in some cases escape observation ; in others, the symptoms are similar 
to those of osteomyelitis with arthritis. If the arthritis is very acute 
and other organs are involved, death may result; but, on the other 
hand, if the joint is evacuated in time, recovery may take place. 
The pneumococcus arthritis involves the tissues surrounding the 
joints. The cartilages of the joint are rarely involved. Pneumo- 
coccus osteitis affects the cortical layers of the bone in the vicinity 
of the epiphyseal line. Large sequestra are rare. Of 41 cases, 15 
occurred in childhood in the first two years of life. 

Of 44 cases of pneumococcus arthritis and osteitis collected by 
Pfisterer, 23 died. Death was due to pneumonia, empyema, menin- 
gitis, endo- or pericarditis. 

Physical Signs. — Clinically the physical signs of bronchopneu- 
monia are divided in those of the following stages : the first stage — 
invasion; the second stage — consolidation; the third stage — resolu- 
tion. There is no sharp line of demarcation between the signs of 
the stages. 

First Stage. — Inspection shows the face to be flushed on one or 
both sides, and the nostrils to be dilated ; with each inspiration there 



DISEASES OF TEE LUNGS. 643 

is drawing inward of the peripneumonia groove and sometime- of the 
suprasternal tissues over the upper part of the trachea. 

If bronchitis is present, there may he rhonchal fremitus, but it 
is frequently absent. 

In the early stage there is, just before consolidation, slight duluess 
over small areas, which in young infants with thin-walled chests may 
have a slightly tympanitic note (tympanitic dulness). Other parts 
of the chest may have a vesiculotympanitic note. 

If bronchitis is present, the rales of bronchitis may be heard. 
The respiratory murmur is rude. By careful examination of all 
parts of the chest one or more areas in which are heard fine crepitant 
rales may be found. They may easily be overlooked, and may dis- 
appear when the infant cries or coughs, and during the examination. 

Vocal resonance is slightly increased over areas in which there 
is slight dulness or beginning consolidation. The whole posterior 
aspect of the thorax from above downward, and also the axillary 
region should be examined. The apex of the lung in front, and the 
lower part of the thorax in front and behind on both sides, should 
be carefully examined, as well as the areas of the borders of the lungs 
where they come in contact with the chest-wall. Increased vocal 
resonance and slight dulness alone, especially over the apex of the 
right lung in front and behind, should be accepted with great caution 
as indicative of the beginning of bronchopneumonia. 

Dyspnoea should not be looked upon as a sign of pneumonia. The 
crepitant rale in a circumscribed area or in several areas is the sign 
pathognomonic of this stage. 

Second Stage. — Inspection shows no condition differing from 
those of the first stage. 

If the area of consolidation is limited, there is no change, because 
the area and the chest are small. If there is effusion in the lower 
portion of the pleural cavity, the fremitus may be diminished over 
the lower part of the chest, although the pneumonia is in the upper 
part. Fremitus is therefore misleading, and is only confirmatory in 
the presence of other signs. 

Percussion reveals dulness in complete consolidation or dulness 
with a tympanitic note in the beginning of consolidation, and also 
flatness if fluid is present over the consolidated area in the lower 
part of the chest. The dulness may involve a very small area or an 
entire lobe of the lung. There may be slight resistance to the per- 
cussing finger over the consolidated area. The unaffected lung is 
hyperresonant. 

Auscultation gives bronchophony and bronchial or bronchovesic- 
ular breathing over the consolidated areas. These are no1 necessarily 
present over consolidated lung. In infants and children there may 



644 DISEASES OF THE RESPIRATORY SYSTEM.' 

only be abnormally rude respiratory murmur and increased vocal 
resonance. Fine crepitant pleuritic rales may be heard over the con- 
solidated area. 

Diagnostic stress is to be laid on complete dulness with bron- 
chophony and bronchial breathing. 

Third Stage. — Palpation will give increased fremitus if the con- 
solidated area is large and there is no fluid over this area. 

As in the first stage, there is dulness to a varying extent, with a 
tympanitic note showing the return of air into the lung. 

Auscultation gives a crepitant rale, as in lobar pneumonia. The 
voice and breathing are less bronchophonic. Dulness may persist for 
days or weeks. In some cases there is fluid, which increases the dul- 
ness or flatness. Dulness, crepitant rales, bronchophony and bron- 
chial breathing are constant features, and are diagnostic. In infants 
and children, bronchophony is more constantly present than bronchial 
breathing. In the bronchopneumonia of the newly born infant it is 
sometimes possible to discover with the small bell of a stethoscope 
areas in which air does not enter (atelectatic). 

Equivocal Signs Likely to be Mistaken for the Beginning of Broncho- 
pneumonia. — In infants and children, the physician is apt to be easily 
misled into a diagnosis of incipient bronchopneumonia. Equivocal 
signs — i. e., signs which are not absolutely diagnostic — are apt to be 
met in certain parts of the chest and in the presence of rational symp- 
toms, such as fever or apparent dyspnoea, undue importance may be 
atached to them. These signs are as follows : 

a. A slightly high note on percussion and an increase of vocal 
resonance or fremitus, with a rude respiratory murmur on the right 
side over the apex in front or behind. It should not be forgotten that 
this region, especially in infants, normally shows varying degrees of 
these signs as compared with the left side. 

b. A slight dulness over the lower part of the chest on the right 
side behind, due to the presence of the liver, is normal. To be 
abnormal, the dulness must be very marked and the vocal resonance 
much increased. The resistance to percussion must be pronounced 
in the absence of more positive signs, to justify a suspicion of the 
beginning of consolidation. 

c. Bronchial or bronchovesicular breathing too near the vertebral 
column behind on either side, between the scapulae, should be cau- 
tiously interpreted. In some infants, the breathing in this region is 
normally bronchovesicular. It is in this region that the diagnosis of 
central pneumonia is so often made — a diagnosis rarely verified by 
the subsequent course of a case. 

d. In some infants and children, especially from six to ten years 
of age, it is found that the fremitus and vocal resonance diminish 



DISEASES OE THE LUNGS. 645 

behind from a short distance below the angle of the scapula to the 
base of the lung; the breathing also is heard less distinctly. A diag- 
nosis of pneumonia or consolidation with fluid requires positive and 
unmistakable evidence very low down behind. The thick muscle- of 
the back and organs behind the thorax, such as the kidney and liver, 
obscure slight signs below the ninth or tenth rib. 

Diagnosis. — Bronchopneumonia should be differentiated from the 
lobar fibrinous form of the disease. In children above five years of 
age this is not difficult; in those under the second year, in whom 
fibrinous or lobar pneumonia is not uncommon, a positive diagnosis 
of lobar pneumonia cannot be made until the stage of consolidation, 
and even at that time only as to distribution. In the main, it is 
made from the course of the temperature. In lobar pneumonia the 
temperature will fall by crisis after the usual period. A marked 
leucocytosis, which increases toward the day of crisis and then rapidly 
diminishes, is also a characteristic feature. There should be also the 
physical signs of lobar consolidation. 

If these symptoms and signs are all present, it may be assumed 
clinically that a lobar pneumonia is present. Such a diagnosis is 
always open to doubt, for a bronchopneumonia may have the lobar 
consolidation and the leucocytosis, but will rarely have the critical 
drop of temperature which occurs in lobar pneumonia. As to the 
onset, bronchopneumonia may set in with a chill, and lobar without 
one. The complications in both forms are identical ; empyema is as 
likely to occur in one as in the other. Lobar pneumonia is rarely 
prolonged in duration if complications are absent, while the broncho- 
pneumonic type of disease is, as a rule, of longer duration and may 
be prolonged into a chronic course. 

Disseminated patches of consolidation in a lung in which there 
is general bronchitis point to bronchopneumonia ; diffuse bronchitis, 
with fine crepitations in the lower lobes of both lungs, to broncho- 
pneumonia. The presence of a primary disease — measles, scarlet 
fever, typhoid fever, and influenza — will also influence the process in 
the lung. The secondary pneumonia is a bronchopneumonic process. 

Prognosis. — The mortality of bronchopneumonia, even under the 
favorable conditions of private practice, is as high as 25 per cent. 
In hospital practice it is much higher, and may reach 50 per cent. 
or more. It is greater in bottle-fed, rachitic, prematurely born, and 
syphilitic infants, and is greatest in the first year of life. The dis- 
ease is especially fatal in newly-born infants, and in cases of gastro- 
intestinal disorder. The mortality rate increases in New York City 
in the months of December, January, and February, during which 
the weather is alternately moist, warm, and cold. Certain years show 
an increased mortality because of the severe nature oi the epidemic. 



646 DISEASES OF THE EESPIRATORY SYSTEM. 

At the bedside, a prognosis is based on the condition of the lung, 
temperature, heart, and the presence or absence of nervous symptoms. 
A persistently high temperature, if there are areas of consolidation 
in both lungs, is of serious import. An abnormal pallor or slight 
cyanosis in a bottle-fed baby, even if well-nourished, is a danger 
signal. Forced and irregular action of the diaphragm is serious; 
marked drawing inward of the sides of the chest, sometimes as high 
as the eighth rob, is a very unfavorable sign in infants. These cases 
show a depression of the suprasternal notch as marked as that which 
occurs in laryngeal obstruction. Repeated convulsions and jaundice, 
with enlargement of the spleen, in rachitic infants indicate intense 
toxaemia. These cases are fatal. Marked tympanites at the end of 
the first week, in connection with diarrhoea and weakness of the heart, 
is an unfavorable symptom. Dyspnoea with respirations irregular in 
rhythm and depth denotes diffuse involvement of both lungs, and is 
present in the unfavorable cases. Cerebral symptoms supervening 
late in the disease are unfavorable. 

The favorable signs are a good muscular quality of the first sound 
of the heart, red lips and warm surface; good reaction after hydro- 
therapy, and periods of quiet sleep with full noiseless breathing, 
movements of the bowels normal or slightly green, and an absence 
of marked tympanites. Caution should be exercised in making any 
prognosis in a bronchopneumonia which shows a marked tendency to 
involve new areas of lung with repeated chills and cyanosis. 

Treatment. — In the treatment of bronchopneumonia of infants and 
children, it should be borne in mind that the disease is a self-limited, 
acute, infectious one, and that there is no remedy which can abort it 
or prevent complications. As in lobar pneumonia, the ill effects of 
the disease must be counteracted as much as possible and the strength 
of the patient supported. Since the patients are of very tender age, 
remedies which are powerful in their ultimate effects are to be care- 
fully avoided. The indications in the treatment are to counteract 
the effects of the temperature and to support the heart. 

Hydrotherapy. — The temperature in the most fatal forms of this 
disease in newborn infants is below the normal at times, and rarely 
reaches a very high point. In other cases of bronchopneumonia in 
older infants, and children, it remains persistently above 103° F. 
(39.7° C). In these cases, as in lobar pneumonia, the various forms 
of hydrotherapy are utilized. Of all the methods, the cold compress 
applied to the chest, as before described, seems to be the most effica- 
cious. Compresses lower than 70° F. (21.1° C.) are not applied. 
The applications may be renewed every hour, if the patient bears 
them well. A compress wrung out in water at 70° F. (21.1° C.) 
will depress some patients, causing cyanosis without reaction. In 



DISEASES OF THE LUNGS. 647 

such cases, as in the lobar cases, I have found the warm bath, 105°— 
107° (40.3°-41.6° C), of the greatest utility in relieving the nervous 
symptoms, such as restlessness and convulsive twitchings. Infants, 
as a rule, will not bear baths below 80° F. (26.6° C). I therefore 
do not utilize the cold full bath in infants. I do not think it advis- 
able to use the bath at 90° F. (32.2° C.) or higher, with cold douch- 
ing of the head and shoulders, to obtain reaction in infants. The 
procedure rouses the patients only momentarily, and the subsequent 
depression is greater. Cold packs over the whole body are also heroic 
remedies, but are advocated by some authors. 

Medicinal. — The heart is supported by means of digitalis, strych- 
nine, camphor, musk, caffeine, and ammonium carbonate. Of these 
agents, the most useful are digitalis, strychnine, and musk. 

Digitalis is administered in the form of the tincture. A drop is 
given for every six months of the age of the patient. It should not be 
used unless the pulse rate is high, and should then be given every three 
hours. It is discontinued after being administered for two or three 
days. The effects of stronger preparations, such as the fluid extract, 
cannot be gauged so carefully as those of the tincture, and they are 
therefore less useful. The cases in which digitalis is of the greatest 
value are those in which there is cyanosis to a mild degree, or exces- 
sive pallor denoting great cardiac weakness. 

Strophanthus may be administered alone or in combination with 
digitalis. The tincture is the form generally used. 

Strychnine is one of the most useful drugs in the treatment. An 
infant six months old will bear grain ^so or %oo (0.0003 or 0.00025) 
very well. Older infants and children bear grain M50 (0.0004) quite 
well. Strychnine should not be used in cases where there is increased 
excitability of the nervous system. 

Atropine, which is so useful in adults, is not well borne by infants 
and children. 

Ammonium carbonate is one of the most useful drugs when for 
any reason digitalis cannot be used. Convulsions or restlessness are 
treated with the bromides of potassium and sodium, which may be 
combined. Chloral hydrate is combined wit'h both, especially where 
one dose of bromide of potassium and chloral hydrate is given per 
rectum. 

I do not use poultices. Some authors use them as a routine 
measure. 

Inhalations of benzoin and turpentine are of doubtful efficacy. 
They do not affect the local lesion in the lung, nor do they act on the 
mucous membrane as they do in catarrhal processes oi the nose and 
throat. In some cases I have seen harm result from overloading the 
atmosphere with the odor o( balsam. 



648 DISEASES OF THE RESPIRATORY SYSTEM. 

The patient should be isolated from the healthy children of the 
family and the room kept at a temperature of from 68° to 70° F. 
(20° to 21.1° C.) and well ventilated. An open wood fire is the most 
satisfactory method of heating and ventilating the sick-room. 

In threatened oedema of the lungs I have found, as in lobar pneu- 
monia, that the right ventricle is best relieved by nitroglycerin, grain 
%oo to %oo (0.0003 to 0.006) at a dose, and by the constant adminis- 
tration of oxygen containing 20 per cent, of nitrous oxide. 

Alcohol is so universally used that the mode of administering 
it should receive special mention. Alcohol should not be used as a 
routine remedy. In some of the milder cases its use is superfluous. 
There are other cases in which its use must be suspended because of 
the constant vomiting. In the severer types of bronchopneumonia, 
in which the temperature is persistently high,, the effects of the tox- 
aemia may be counteracted by administering whiskey. Infants receive 
from minims xx to xxx (1.2 to 2.0) ; older children a drachm (4.0) 
every three hours. The whiskey should be well diluted, and should 
be given after the nursings. 

The feeding of infants who take a substitute for the breast should 
be carefully watched, especially in bronchopneumonia, a disease in 
which diarrhoea is apt to supervene. If diarrhoea is present, the milk 
should be discontinued and a cathartic given. The infant is given 
a high rectal injection of warm normal saline solution twice daily, 
and is kept on solutions of egg-albumin and acorn cocoa and cereal 
gruels until the intestinal symptoms subside. Milk is then again 
given. In these cases of intestinal disorder it is of the utmost im- 
portance to see that the milk is fresh and uncontaminated. 

The cases not complicated by diarrhoea are given a warm high 
rectal enema of the normal saline solution once daily. In infants, 
this procedure will ward off tympanitic distention of the abdomen 
and stimulate the heart. 

The cough is sometimes very harassing, and then only should be 
relieved. The camphorated tincture of opium or the wine may be 
given in moderate doses. Codeine is useful in older children. In 
the many hundreds of cases which I have treated I have not found it 
necessary to use morphine. Strapping the chest to relieve pain is 
harmful in infants and children. The chest in these subjects is resil- 
ient, and any limitation of its motion reacts unfavorably in prevent- 
ing a full expansion of the unaffected lung. 

Persistent Bronchopneumonia {Chronic Bronchopneumonia).— 
Persistent bronchopneumonia is a distinct type of bronchopneumonia 
the course of which extends over weeks or months, the patient mean- 
while becoming much reduced in flesh and strength. These cases 
occur in weakly infants, usually in those who are bottle-fed. A dis- 



DISEASES OF TEE LUNGS. 



649 



tinct type of the disease complicates 
chronic enteric catarrh. Cases of this 
class belong in the category of Gastro- 
intestinal Sepsis of Fischl, Escherich, 
and Czerny. Cases of another set com- 
plicate and follow pertussis, measles, 
and influenza. Lastly, there is a true 
tuberculous form which is not strictly 
included in the above classification. 
The condition is thus rarely primary. 

Symptoms. — The infant or child has 
at first the symptoms of an ordinary 
bronchopneumonia. The fever, however, 
is of longer duration than in cases which 
recover. Cases of gastro-enteric affec- 
tion or pertussis will continue to have 
a remittently high temperature which 
may reach 105° (40.5° C), but fall to 
101° or 100° (38.3° or 37.7° C.) on 
the same day. It will remain normal 
for days, and then rise again, as indi- ! 
cated in the chart (Fig. 136). There 
are cough, dyspnoea, emaciation, and I 
gastrointestinal disturbances. In cases 
of enteric catarrh the intestinal disease 
takes clinically a secondary place. Some 
of these cases eventually recover in spite 
of the progressive emaciation and high 
fever. This is especially the case in per- 
sistent bronchopneumonia which com- 
plicates pertussis. 

Blood. — In the case from which the 
chart was taken there was a distinct 
increase of the number of leucocytes 
with each new rise of temperature and 
fresh invasion of the lung. The num- 
ber of leucocytes mounted as high as 
80,000 to the cubic millimetre. A dif- 
ferential count showed that the poly- 
nuclear neutrophiles ranged a1 differenl 
times from 73 to 83 per cent, of the 
leucocytes and the small Lymphocytes 
(mononuclear) from 13 to 21 per cent. 
As the disease progressed, there were also 
mierocyles, megalocytes 



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650 DISEASES OF TEE EESPIEATOEY SYSTEM. 

Physical Signs. — On examination, there are found areas of con- 
solidation of varying extent, generally made out posteriorly over the 
apex or toward the base of the lung. There are signs of general bron- 
chitis, increase of fremitus, and dulness marked, slight, or combined 
with a tympanitic note. There may be fine crepitations here and 
there over the chest. If the areas are extensive, there may be bron- 
chophony or bronchial breathing. The complete consolidation of 
primary bronchopneumonia is not always present. The lung is only 
partially consolidated, so that the vocal resonance may simply be 
markedly increased or the breathing may be bronchovesicular. 

Diagnosis. — Persistent bronchopneumonia may be suspected if 
there is an area of dulness at the apex or in the midregion lower lobe 
posteriorly of one or both lungs which does not resolve after a lapse 
of weeks. The persistence of fremitus on the affected side, espe- 
cially in the midregion of the chest behind, will aid in excluding the 
presence of fluid if the area of consolidation is located in the mid- 
region, base or lateral aspect of the lung. The rest of the lung is in 
these cases resonant or hyperresonant. In doubtful cases the explor- 
ing-needle should be introduced into the chest to ascertain whether 
fluid is present. 

Treatment. — The treatment is practically an extension of the treat- 
ment of the primary condition. If there is an affection of the gastro- 
enteric tract, it is treated. If there is pertussis, treatment proceeds 
on the lines usually followed in that affection. In some cases the 
administration of iodide of potassium in small doses has seemed to 
have a beneficial effect on the course of the process in the lung. 

DISEASES OF THE PLEURA. 

Pleurisy (Pleuritis). — Pleurisy in infancy usually occurs as a 
secondary disease ; it is rarely primary. 

Dry Pleurisy. — Dry pleurisy is the form in which the pleura is 
inflamed without any appreciable formation of exudate in the pleural 
cavity. 

Pleurisy with Effusion. — Pleurisy with effusion, or subacute pleu- 
risy, as it is incorrectly called, is the form in which a serous or sero- 
fibrinous effusion is found in the pleural cavity. The form in which 
the effusion is of a seropurulent or markedly purulent character is 
also called empyema. 

Empyema. — Empyema is therefore a purulent or suppurative 
pleurisy. There are other forms of pleurisy which occur with neo- 
plasms of the lung or pleurae. These are not discussed in this section. 

Dry Pleurisy. — Frequency. — Dry pleurisy, pure and simple, is, in 
my experience, clinically not common among infants and young chil- 



DISEASES OF THE PLEURA. 651 

dren. As an independent affection, it is found more frequently after 
the fifth year of life. Clinically, the cause of this infrequency in 
infancy cannot be easily explained. Young infants and children 
rarely indicate the pain which is the leading symptom. The disease 
is masked by other symptoms occurring at the same time. Older 
children locate the pain and direct attention to it. 

Etiology. — This form may be primary or secondary. As a pri- 
mary affection it is found in rheumatic subjects, especially those who 
are or have been subjects of disorders such as endocarditis or fibrinous 
adhesive pericarditis. In these cases the etiology is the same as that 
of rheumatism. The condition is secondary to pneumonia. It may 
be found complicating any of the infectious diseases — influenza, scar- 
let fever, measles, typhoid fever, or tuberculosis. In such cases the 
bacterial factor in the etiology is much the same as in the forms which 
will be considered under Pleurisy and Effusion. Pleurisy may com- 
plicate nephritis of the subacute or chronic type. Traumatism will 
cause this form of pleurisy; exposure to cold or wet will predis- 
pose to it. 

Symptoms. — The cases of simple dry pleurisy not proceeding to 
the formation of effusion in the pleura, which have come under my 
notice, gave few symptoms. 

Pain. — The children in the majority of cases complained of dis- 
tinct localized pain on exertion or on deep inspiration. There is 
also some local pain on external pressure. I have seen marked pleu- 
risy of the dry form in which pain was absent. This is most likely 
to occur in pleurisies secondary to nephritis. In the primary type, 
the patients continue to walk about, but are pale and have an anxious 
expression of the face. There is sometimes a rise of a degree or more 
in temperature and the respirations are increased and superficial. 
Those forms described by Henoch as setting in with convulsions, 
high fever, and vomiting, have not in my experience remained dry 
fibrinous pleurisy, but have proceeded to the formation of effusion 
in the chest. The duration of dry pleurisy is variable, and in the 
rheumatic forms may extend over a long period of time. 

Diagnosis. — The diagnosis is not difficult, and is made from the 
physical signs and the history. On examination, a localized area over 
which there are a large number of dry crepitant rales is found. The 
rales are heard so close under the ear that they are distinguishable 
from the crepitant rales of pneumonia. In some cases there is a 
dry rubbing sound — a pleuritic friction — over the area affected. In 
the cases without complications there are no other signs. There is 
little or no dullness and no change in the voice or breathing-sounds. 

Prognosis. — The prognosis is very good. Tuberculous disease of 
the lung is not a causative agenl in these eases in children so fire- 



652 



DISEASES OF THE XESPIBATOET SYSTEM. 



quently as in the adult. The primary dry pleurisies, with proper 
care, subside and gradually disappear. 

Treatment— The treatment of dry pleurisy is very simple. If the 
subjects are rheumatic, they are put on small doses of salicylate of 
sodium. The bowels are kept open with a saline cathartic, preferably 
Carlsbad salts. The patients are kept in bed. It is not advisable to 
strap the chest to relieve pain. The desired relief can be secured hv 
some local application of iodine or a sinapism. Codeine is admin- 
istered m moderate doses to relieve the cough and pain. 

Pleurisy with Effusion (Subacute Pleurisy) and Empyema (Pur- 
ulent or Suppurative Pleurisy).— Frequency.— This form of pleurisy 
is common m infancy and childhood. The largest number of cast- 
occur before the fifth year (Simmonds). The succeeding five years 
show the next greatest frequency. Israel found 29 per cent, of 206 
cases to be purulent. Mackey estimates the purulent cases at 40 per 
cent, of the whole number in children, as against 5 per cent, in adult' 
Combining ttie statistics of Simmonds and Hofmokl of Vienna this 
form is found to have greater frequency in the male sex. According 
to these authors, the left side is more often the seat of the disease 
bimmonds found the disease to be bilateral in only 7 out of 175 cases. 
Of 1/0 of my own cases of empyema, 3 were bilateral. Of these 
he majority occurred before the fifth year, and 25 per cent, before 
the age of two years. The youngest patient was two months of age 
Etiology. —Primary pleurisy, whether suppurative or serous,"is 
rare, the literature contains cases of acute effusion in the pleural 
cavity in which there was apparently no exciting cause or primary 
lung affection. The etiology must in such cases remain in doubt 
Infection may take place through so many avenues that it is difficult 
to point out the mode of entrance. 

Pleuritis, serous or purulent, is generally secondary in infancy 
and childhood. All forms of lobar or bronchopneumonia may give 
rise to pleurisy, most of the cases being traceable to this source " The 
infections diseases— measles, scarlet fever, pertussis, typhus and 
typhoid fever diphtheria, forms of tonsillitis, retropharyngeal and 
mediastinal abscess, may precede or directly cause an attack of pleu- 
risy. Chronic intestinal sepsis may cause empyema. In the latter 
case a pneumonia generally precedes the pleurisy or is present at the 
same time. In sepsis of the newly-born infant, there may be a com- 
plicating empyema. Osteomyelitis of the septic streptococcus variety 
may be complicated by purulent pleurisy. 

Tuberculous disease of the lung, actinomycosis of the lung, abscess 
of the liver abscess in the mediastinum and abscess in the abdominal 
cavity involving the viscera, may cause pleurisy. Appendicitis may 
alter the formation of abscess cause pleuritis by extension of the 



DISEASES OF THE PLEURA. 653 

process along the coils of large intestine to the diaphragm. Finally, 
rheumatism may cause pleurisy of a serofibrinous nature- Exposure 
to cold and wet is undoubtedly a predisposing cause. In children, it 
is common to have a history of a fall or a blow occurring just prior 
to the attack of pleurisy. 

Morbid Anatomy. — Pleurisies which accompany acute pneumonia 
are the most frequent. In these, there may be a slight injection of 
the pulmonary pleura and a loss of the normal lustre. Here and 
there a few fibrinous threads or adhesions may be found coursing 
over the surface of the pleura or running from the costal to the pul- 
monary pleura (dry or fibrinous pleurisy (pleuritis sicca)). In 
other cases, there is a thickened condition of both pleural reflections, 
caused by the deposit of fibrin on the surface. Sometimes the amount 
of fluid is small, while the pleura is very much thickened. The 
pleura itself may be little altered ; underneath the fibrin the lymph- 
spaces and bloodvessels may be dilated. In some cases there is also 
a serous or seropurulent exudate containing leucocytes, endothelial 
cells, and bacteria. The fluid may be clear or bloody, turbid or 
opaque, yellow or greenish, and thin or creamy inconsistency. Large 
clots of fibrin may be found floating in the exudate. Adhesions may 
form pseudo-encapsulations of exudate, binding down the lung and 
preventing its expansion. In children, however, the tuberculous 
pleurisies are most likely to cause extensive thickening of the pleura. 
In addition to the deposit of fibrin on the costal and pulmonary 
pleura, there is a real inflammatory thickening of the tissue of the 
pleura itself, with a deposit of tubercle tissue. 

Serous or purulent exudate is encapsulated by adhesions, while 
the lung is bound down by layers of inflammatory tissue. In the 
tuberculous form the changes are progressive. In the acute inflam- 
matory forms, the exudates are absorbed and the fibrinous deposit is 
organized into new connective tissue. In time the pleura may be 
restored to the normal. Adhesions, however, form an important 
factor in acute pleurisy of children. The pleura may in some cases 
be permanently thickened by a new layer of connective tissue persist- 
ing throughout life. There are forms of pleurisy not tuberculous in 
which this thickened condition not only remains, but extends from 
the pulmonary pleura into the lung along the interlobular tissue of 
the lung itself. There are induration and destruction of lung tissue. 
This induration is seen in connection with persistent bronchopneu- 
monia. The aniouul of effusion (purulent) is sometimes quite large 
in children, and may reach 1000 to 5000 cubic centimetres (Sim- 
monds, Hofmokle). In scurvy and morbus Werlhofii, blood may be 
effused into the pleural exudate. 

Bacteriology.- Pleurisy or empyema is divided into several groups 



654 DISEASES OF THE BESPIEATOBY SYSTEM. 

according to the class of bacteria found in the exudate. It is well 
established that the bacteria are the essential cause of the disease. 

The first and largest group is that in which the pneumococcus of 
Frankel, the lanceolate diplococcus, is found. These cases are called 
metapneumonic. They may occur during the progress of a pneu- 
monia or after it has run its course. In some cases the process in the 
lung plays clinically a secondary role. The pneumococcus seems to 
occasion very little disturbance in the lung and to spend its force on 
the pleura. Thus within three days after the initial chill the pleura 
is filled with serous or seropurulent fluid, better found that of 28 
pleurisies in infants and children 53 per cent, were due to the pneu- 
mococcus. In 212 cases of empyema I found the pneumococcus by 
culture in 75 per cent. 

The second group comprises those cases in which the streptococcus 
alone, the staphylococcus, or the streptococcus with the pneumococcus 
or staphylococcus, is found, better found that 17 per cent, of his 
cases were of the streptococcus class ; 10 per cent, of my cases were 
due to this micro-organism. In cases of the septic type, such as com- 
plicate sepsis of the newborn or osteomyelitis, or follow scarlet fever, 
the Streptococcus longus is found in the exudate. These cases are 
severe. Six per cent, of my cases were caused by the staphylococcus. 
In 9 per cent, of my cases of empyema the streptococcus and pneumo- 
coccus were both found in the exudate. Although the pleurisies in 
which the streptococcus and staphylococcus are found may follow a 
pneumonia, they may also be secondary to a follicular amygdalitis, 
the exanthemata, typhoid fever, influenza, diphtheria, sepsis, and 
osteomyelitis. 

The third group of cases comprises those in which either the 
tubercle bacillus is found in the exudate, or the exudate is free from 
micro-organisms. The latter condition is frequently presumptive 
evidence of a tuberculous infection (Ehrlich). The tubercle bacillus 
was found in 1 per cent, of my cases, while in 3 cases the findings 
both by cover-glass spread and culture were negative. This would 
at most give a frequency of 2 per cent, for the tuberculous variety 
of pleurisy or empyema. 

The last group is that in which micro-organisms other than those 
mentioned are found in the pleuritic exudate. Such cases have been 
observed in connection with typhoid fever in which the Eberth bacillus 
has been found. Escherich has found the coli bacillus in a case of 
empyema. I have seen one case of this kind. The bacilli of the 
saprophytic variety and those which cause a putrid empyema are 
found in cases of this fourth class. 

The following table shows the relative frequency of the various 
forms of pleurisy and empyema with the varieties of bacteria in the 
exudate : 



DISEASES OF THE PLEURA. 



65o 



Children. 



Netter 
28 cases. 
Pneumococcus 53.6 per cent. 

Pneumococcus and Streptococcus 3.6 " 

Streptococcus 17.6 " 

Staphylococcus 

Putrid 10.7 

Tubercule bacillus 14.3 " 



KOPUK 

212 cases. 
7o per cent. 

9 
10 

6 

2-3 



Adults. 



17 per cent. 
2.5 " 



1.2 

25 



Fig. 13; 



Pig. 138. 





Fig. 139. 



Fig. 140. 




Fig. 137. — Streptococci from the pus of empyema ; pure culture. Photomicrograph. \ 1000. 

Pigs. 138 and 139. — Pneumococci (Diplococcus lanceolatus) from the pus of empyema. 
Cover-glass preparations showing capsule. Photomicrograph. \ 1000. 

Fig. 140. — Pneumococci (Diplococcus lanceolatus) ; pure culture from the pus of em- 
pyema. Photomicrograph, x 550. 



The most important fad to be deduced from the statistics is that 
while tuberculous pleurisy in children lias a frequency o\ -2 to 3 per 



656 DISEASES OF THE BESPIBATOBY SYSTEM. 

cent., adults show a much greater frequency, many of the strepto- 
coccus cases being tuberculous in the latter subjects. This figure 
added to the number of cases in which tubercle bacilli are found in 
the exudate would bring the frequency in the adult to at least the 45 
per cent, given by Bowditch as the relative figure. 

Physical Characteristics. — The physical characteristics of an effu- 
sion in the chest are of clinical importance. An effusion if purulent 
has usually the gross physical characteristics of ordinary pus. In 
some cases the effusion is at first clear and serous, but is subsequently 
seen to be purulent without the occurrence of any extraneous infec- 
tion. In other cases the effusion may be a cloudy serum, which on 
exploratory puncture is after a few days found to be purulent. In 
rare cases the effusion or exudate in the pleura is hemorrhagic. An 
effusion of that character has not the same significance in children 
as in adults. In the latter such effusions may be tuberculous or due 
to some morbid growth of the pleura ; this is not necessarily the case 
in children. I have had a number of cases of hemorrhagic effusion 
into the pleural cavity. In none of them was there a tuberculous 
element. In all, streptococci were found in the effusion, and in some 
the admixture of blood could be traced to a scorbutic tendency. In 
one case, in an adolescent with localized effusion of a hemorrhagic 
nature, there was an actinomycosis of the pleura and lung. The 
history of this case was not that of an effusion of an acute, but of a 
subacute chronic nature. 

Symptoms. — There are no symptoms characteristic or pathogno- 
monic of effusion in the pleura or empyema. The condition is in most 
cases masked by the symptoms of the causal affection. Cases following 
a pneumonia set in with a chill or a rapid rise of temperature, with 
which there may be a convulsion followed by stupor or cerebral symp- 
toms. After this onset the fever continues, ranging from 103° to 
105° F. (39.4° to 40.5° C). the pulse being 140 to 180. There will 
be cough, great dyspnoea, and pain in the chest, which is especially 
manifest when the infant or child coughs. The breathing is shallow. 
After a few days the acute symptoms subside, the fever becoming 
remittent. The temperature may be nearly normal. The dyspnoea 
continues, although the temperature and pulse may be normal during 
part of the day. 

In some of the cases the effusion becomes apparent on the eighth 
day ; in others a purulent effusion is found in the chest on the twelfth 
or fourteenth day of the disease. The effusion, which finally becomes 
apparent in the chest, has been coincident in its onset with a pneu- 
monia — there has been a pleuropneumonia. The process in the lung, 
however, takes a secondary place in the clinical picture when the 
effusion in the pleural cavity has accumulated. 



DISEASES OF THE PLEURA. 



657 



There is another set of eases in which the course of the disease 
is insidious. The patient may at the onset have had for two or three 
days a febrile movement which has subsided, leaving the child not 
quite well and with a slight febrile movement toward evening, a slight 
hacking cough, and some little pain in the chest on exertion. Langour 
and loss of strength are progressive. There may be exhausting sweats 
at night. Examination of the chest will reveal an effusion. 

The metapneumonic pleurisies in infants and children have a 
characteristic course. The patient has a typical pneumonia. The 
temperature on the ninth, tenth, or thirteenth day may drop to the 
normal or subnormal, the respirations continuing high. A gradual 
rise of temperature follows, with physical signs of fluid in the chest 

























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Lobar pneumonia ; fall of temperature, by lysis ; gradual rise after the thirteenth 
day, due to empyema leucocytosis. Operation on the nineteenth day. Recovery. Boy, 
four years of age. 

(see Fig. 127). The pulse and respirations rise with the tempera- 
ture. Toward evening there may at times be chilly sensations. Ex- 
ploration may discover fully developed effusion in the chest, serous 
or purulent according to the severity of the pleuritic infection. As 
a rule the younger the subject, the more likely is the effusion to be of 
a purulent nature. The duration of the effusion in the chest will 
also be a guide in determining its nature. An effusion occurring 
after pneumonia in a young infant and persisting for a week after 
the pneumonia has run its course, is likely to be purulent. 

Diagnosis. — There are some symptoms, such as continued dyspnoea, 
a slight or troublesome cough, exhausting sweats, and a distinctly 
intermittent range of temperature, which in cases of pulmonary dis- 
ease should direct attention to {he pleura. None of these symptoms 
is, however, pathognomonic of pleurisy, serous or purulent, since they 
may be found in other pulmonary conditions. The diagnosis of pleu- 
risy with effusion or empyema should take into consideration not 
only the rational symptoms, but also the physical signs. 

Physical Signs. The physical signs o( pleurisy with effusion and 
of empyema are identical. 
42 



658 



DISEASES OF TEE KESPIBATOEY SYSTEM. 



Fig. 142. 



Fluid in the Chest. — 1. The chest partly filled with fluid. 2. 
The chest full of fluid. 

1. The Chest Partly Filled with Fuid. — It is assumed that the 
greater part of the fluid is in the lower portion of the chest (Fig. 
142). In children and infants it does not cause displacement of the 

viscera. 

Inspection. — Inspection may show 
fulness of the lower part of the affected 
side ; the lower part of the chest moves 
less than the opposite side. 

Palpation. — Vocal fremitus will be 
felt over the upper portion of the chest 
in front or behind, and will be lost over 
the lower portion. 

Percussion. — Percussion of the chest 
in front will often give an exaggerated 
hyperresonant tone over the upper lobe 
of the lung. Behind, there is almost 
always dulness to a greater or less degree 
above over the scapula, due either to thick- 
ening of the pleura or to an exceedingly 
thin layer of fluid. This dulness can be 
distinguished from dulness due to other 
causes by firm percussion which will elicit 
the pulmonary note of the underlying 
lung. Below, over the fluid, the dulness changes to complete flatness. 
Auscultation. — The voice and breathing may be heard over the 
whole side with as much intensity as on the healthy side, or with 
diminished intensity below the level of the fluid. Rales, generally 
pleuritic crepitations, may be heard above the level of the fluid. 
Bronchial breathing and voice may be heard over the fluid or at the 
level of the fluid, but this sign is not absolute. 

Diagnosis to justify needle exploration must be based on absence 
of vocal fremitus over the fluid and its presence above the fluid, 
dulness behind above the fluid, which on firm percussion gives a faint 
pulmonary tone and flatness over the fluid with slightly increased 
resistance to the percussing finger. 

Note. — The method of examining infants for fluid is invariably 
that indicated in the earlier part of the book. It is a mistake to 
examine the infant as it lies in the lap of the mother, for in this 
position the fluid will gravitate. When the infant lies on the face, 
the fluid will again gravitate to the anterior part of the chest and 
thus not be made out. In the earlier stages of pleurisy the fluid 
only partly fills the thorax. On account of the small size of the 




Pleural cavity partly filled with 
fluid. 



DISEASES OF THE PLEURA. 



659 



thorax in infants, it is impossible to determine the change of level of 
the fluid by changing the position of the patient. 

The resonant note or Skodaic resonance over the lung apex in 
front should, in the presence of dulness behind and flatness below, 
always arouse suspicion of fluid, for in these cases the lung is com- 
pressed upward, forward, and inward, thus causing the vesiculo- 
tympanitic or amphoric note in front and above. 

The chest is partly filled with fluid, as is shown in Figs. 143 and 
144. I have quite frequently found this condition in infants and 
children who have for a long time lain on the back, and in whom 
adhesions have kept a layer of fluid in the position shown in the figure. 
It will be assumed for illustration that the right side is affected : 



Fig. 143. 



Fig. 144. 





Fluid in a thin layer posteriorly in the pleura. 



Inspection. — On inspection, fulness of the intercostal spaces on 
that side may be detected ; the movement of the thorax is labored, and 
the intercostal spaces may be drawn inward on inspiration. 

Palpation, — Vocal fremitus due to the lung's being in contact 
with the chest-wall may be present over the anterior aspect of the 
chest. Posteriorly, the fremitus will be entirely absent. 

Percussion. — Anteriorly, the note may be vesiculotympanitic; 
posteriorly, there is complete dulness over the whole chest, which is 
more marked below. There is rarely the flatness obtained as when 
the chest is full or half full of fluid. There is also resistance to the 
percussing finger. 

By percussing firmly the note of the lung beneath will invariably 



660 



DISEASES OF THE EESPIEATOEY SYSTEM. 



be elicited ; breathing-sounds and voice-sounds will be heard as normal 
or distant. 

Pleuritic Crepitations. — Pleuritic crepitations may be heard over 
the whole affected side ; there is no displacement of the liver or heart 
on the left side. 

Diagnosis of fluid before exploratory puncture must rest on the 
complete or partial absence of fremitus behind, and complete dulness 
or flatness. The quantity of fluid is small; there is less resistance 
to percussion than when it is large. 

2. The Chest Full of Fluid {Bight Side). — Inspection. — On 
inspection the objective signs of intense or moderate dyspnoea are 
found: The chest on the affected side is immobile; the intercostal 
spaces are retracted with each inspiration; the affected side bulges 
visibly. 

Fig. 145. Fig. 146. 





Pleural cavity full of fluid. Flatness 
anteriorly and posteriorly. 



Pleural cavity filled with fluid. Lung 
displaced upward and forward. Reso- 
nance anteriorly over the apex, either 
vesiculo-tympanitic or of the cracked- 
pot quality. 



Palpation. — Vocal fremitus is lost over the whole side in front 
and behind. In rare cases some fremitus is felt. 

Percussion. — Ordinary and firm percussion give a flat note over 
the whole chest in front and behind ; the resistance to the percussing 
finger is wooden. In front, flatness may be present over the apex of 
the lung (Fig. 145). In some cases the note over the apex of the 
lung may be amphoric or cracked-pot as over a cavity. This is due 
to lung compression. In other cases the resonance in front, over the 



DISEASES OF THE PLEURA. 



661 



lung of the affected side is vesiculotympanitic, owing to the pushing 
upward and forward of the lung and to its distent ion. 

Displacement of the Pleural Fold underneath the Sternum. — A 
very important aid in the diagnosis of fluid in either side of the chest 
is the displacement of the line of the reflection of the pleura in front. 
Normally the pleura? of both sides meet underneath the sternum in 
the median line. Above, at about the level of the second rib, they 
depart gradually from each other. If there is a large amount of 
fluid in the right chest, the pleural fold of that side becomes distended 



Fig. 14' 




Displacement of the left pleural fold in effusion (empyema) into the left pleural cavity 
flatness to the right of the midsternum as indicated. 



and displaced to the left, and may be marked out above the heart by 
dulness to the left of the midsternum. If the left chest is full oi 
fluid, the left pleural fold is displaced to the right and there is 
distinct dulness or flatness above, to the right of the midsternum 
(Fig. 147). 

Auscultation, — Auscultatory signs in infants and ehildreu are 
most puzzling when the chest is full of fluid, and little diagnostic 
value can be attached to them in some cases. The chesl may be full 
of fluid while the breathing and the voice mav be heard as on the 



66"2 DISEASES OF THE RESPIRATORY SYSTEM. 

unaffected side, and pleuritic crepitant rales or crepitations may be 
heard over the whole chest behind. In other cases, the breathing may 
be indistinct and distant, and in the lower part of the chest lost en- 
tirely. The voice may be bronchophonic in certain localities ; it may 
be of this quality over the whole diseased side of the chest behind, 
or the tubular sound may be conducted to the healthy side. The 
voice may be normal above and heard faintly below, toward the base 
of the lung. 

Diagnosis before exploratory puncture rests mainly on (a) com- 
plete absence of fremitus; (b) absolute flatness on percussion with 
resistance to percussion;- (c) bronchial voice and breathing over the 
whole chest behind; (d) hyperresonance over the apex, and displace- 
ment of viscera, and of the pleural fold in front. 

Displacement of Viscera. — Liver. — In infants and young chil- 
dren the presence of fluid may be indicated by displacement of the 
liver downward on the right side. I have been able to verify the dis- 
placement in cases in which large amounts of fluid were present. In 
infants, the liver is so large and the projection below the border of 
the ribs so undetermined, that it is difficult to estimate the exact 
amount of displacement. The chest is so easily dilated that an ordi- 
nary amount of fluid accommodates itself without markedly displac- 
ing so heavy an organ as the liver. In children I have been able to 
make out a displacement of the liver downward before the evacuation 
of large quantities of fluid. Displacement is of confirmatory value 
in diagnosis. 

Heart. — The heart-apex may be displaced toward the median line 
by fluid in the left pleural cavity. In children, when the amount of 
fluid is large, the apex is displaced and lies beneath the lower part 
of the sternum. A small amount of fluid will not always cause dis- 
placement, but will find its way around the heart. 

Remarks upon the Diagnosis of Fluid in the Chest, with Exceptional 
Signs. — It is not always easy, even for the expert, to decide without 
puncture as to the presence or absence of fluid in the chest of infants 
and young children. The following signs will be of service at the 
bedside. 

Duration of Illness. — If an infant or child has been ill for two 
weeks or more with signs of pneumonia during the early part of the 
disease, the physician should be watchful in the presence of the fol- 
lowing conditions : If the temperature does not fall, but though remit- 
ting still continues ; if the signs of consolidation of a small or large 
area give place to dulness or flatness over a whole side behind, with 
bronchophony over the whole side — for if the condition of the infant 
is tolerably good, it is evident that such bronchophony may not be 
due to the total consolidation of the whole lung, especially if there is 



DISEASES OF THE PLEURA. 663 

displacement of viscera, chiefly of the liver or the heart; if there 
is drawing inward of the intercostal spaces during inspiration, with 
real immobility and bulging of a side and dulness or flatness and loss 
of fremitus. 

Fluid is very rarely encapsulated in a small area behind, about 
the midregion of the chest. Such areas are usually areas of per- 
sistent bronchopneumonia. In most cases, there is localized dulness, 
above and below which there is vesiculotympanic resonance, normal 
pulmonary resonance or exaggerated resonance. There is distinct 
respiratory movement of the affected side. On the other hand, a 
collection of fluid between the lobes of the lungs (interlobar) may 
give a localized flatness and all the auscultatory signs, such as bron- 
chial voice and breathing, of a local collection of fluid. This is gen- 
erally found in the midaxillary line or slightly toward the posterior 
axillary line on either side. 

There are certain localities in which the diagnosis of fluid must 
be made with reserve : 

a. In a case on which I operated, fluid was found posteriorly over 
the situation of the upper lobe of the right lung. The fluid was com- 
pletely shut off from the rest of the pleural cavity by a membrane 
stretching from the thoracic wall to the interlobar fissure of the lung. 
Postmortem showed the case to be tuberculous, the lung on the affected 
side being the seat of persistent tuberculous bronchopneumonia. I 
have seen similar cases which were metapneumonic. 

b. Fluid over the upper lobe in front only is rare. I have seen 
four cases in which the empyema was localized over the apex of the 
lung on either side. The signs in these cases were diagnostic. There 
was flatness on percussion, resistance to the percussing finger and 
complete absence of respiratory murmur. 

c. Fluid over the lower lobe of the lung, in front on the right or 
left side without corresponding signs behind, is uncommon. 

d. Circumscribed collections of fluid behind over the middle re- 
gion of the lung or toward or in the axillary line are exceedingly 
uncommon. 

e. In the chapter on the physical signs of pericarditis, it will be 
shown how a pleurisy or empyema on the left side may be mistaken 
for pericardiac effusion. 

Physical signs having led the physician to suspect fluid, the chest 
should be explored for two distinct reasons: to determine absolutely 
the presence of fluid, and to ascertain whether it is serous or purulent. 

Diagnostic Exploratory Puncture of the Chest. — Instruments. — The 
instruments necessary arc an exploring needle, a millimetre in calibre, 
and an aspirating syringe. The needle should not be too short, else 
it, may snap off in the Aw>\. The needle and syringe aiv boiled for 



664 DISEASES OF THE BESPIEATOET SYSTEM. 

a few moments before being used. The patient is held in the arms 
of the nurse or mother, so that the posterior aspeet of the chest mav 
be exposed. Older children may sit on a table. The chest is scrubbed 
with soap and water, washed off with other, then with alcohol, and 
imaiiy with a solution of sublimate (1:2000). The arm* of the 
infant or child are firmly held and the chest steadied in such a manner 
that should the patient start suddenly the needle will not break in the 
chest (Plate XXIX). 

[Ruction of the Needle.-The chest is again percussed and 
the needle introduced into the intercostal space in which percussion 
elicits the most marked dulness or flatness. This rule should be 
invariably followed; the needle should not be introduced into any 
particular intercostal space. On the right side the physician should 
avoid putting m the needle too low down (liver) ; on the left side he 
should avoid introducing it too deeply for fear of wounding a large 
vessel at the root of the lung. The needle should not be entered too 
near the vertebral column. The needle having been introduced one 
or two centimetres, the piston is drawn and held thus a few seconds 
Sometimes the fluid is thick and does not flow freely into the svrin^e' 
ihe syringe should not be introduced and then withdrawn and pointed 
up and down m various directions in quest of fluid, for fear that the 
struggles of the patient, even if he is firmly held, will cause puncture 
of the lung and bloodvessels. The needle should be withdrawn as 
rapidly as it was introduced and the whole operation completed in 
less than a minute The external wound is covered with a small strip 
of sterile gauze held in place with rubber plaster. The needle while 
m the chest should be held loosely. If it is held firmly, any sudden 
movement of the patient will cause it to break off in the chest The 
needle should not be introduced too deeply lest it mav enter a dilated 
bronchus and withdraw purulent secretion which mav be mistaken 
for empyema, or that it may wound the lung and cause hemorrhage 
or pneumothorax. fc 

Perforating Empyema. -An empyema may perforate externally 
In that case there will be an extensive infiltration of the tissues ex- 
ternal to the ribs on the affected side, resembling a large phlegmon 
and the signs of fluid will persist. If the perforation occurs on the 
left side, the movements of the heart are likely to he conducted to the 
external swelling, and there is then what has been called pulsating 
empyema. The empyema may perforate through the lung and the 
signs will then vary with the length of time during which the perfora 
tion has existed. It is customary for writers to repeat one another 
in recounting the physical signs of pneumothorax in a chest in which 
fluid (pleurisy or empyema) is present. In infants or very youno- 
children the following classical signs of pyopneumothorax observed in 



PLATE XXIX 




Showing the correct position of the child and operator in 
making an exploratory puncture for fluid in the pleural 
cavity. The plate is not intended to illustrate the point of 
puncture, which is always at the discretion of the operator. 






L 



DISEASES OF THE PLEURA. 



6(55 



adults are not commonly found; amphoric breathing, amphoric voice, 

metallic tinkle and succussion-sounds. My canes were in children 
under two years of age. The perforation in the lung must have been 
too small or too valvular to permit of the entrance of much air into 
the pleural cavity. These cases at first showed all the signs: of the 
condition which was proved, on introducing the needle, to be em- 
pyema. Operation being refused, after a few weeks (three months 
after the beginning of the disease), the signs changed as follows : 

Periodic expectoration of large quantities of pus following couch- 
ing spells. 

Fremitus diminished over the whole right side and almost lost 
below. 

Dulness over the whole side in front and behind, with tympanitic 
note on deep percussion only. Voice normal; breathing normal- — at 
least not varying from that on the healthy side. In the intervals of 
expectoration, there were in some cases bronchial voice and breathing. 



Fig. 148. 



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DISEASE I* O * 

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RESP. S co ' e 


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n 







Empyema, 
the 



left pleura, 
apex of the 



followed thirteen clays after operation by bronchopneumoni 
•ight lung. Male child, twenty months of age. Recovery. 



i at 



_N"o succussion-sounds, no tinkling, no amphoric signs. The class- 
ical signs seen in adults are met in children above five years of age. 

Course and Termination. — Pleurisy with effusion and empyema 
have been considered together, because, in infants and children under 
two years of age, the effusion in the chest may at first be serous, bur 
subsequently change into purulent exudate. A serous effusion may 
be followed by a purulenl one; it may remain serous and be absorbed 
as such. Thus it is best, especially in infants, to introduce an 
exploring-needle into the chest to determine the nature of the fluid 
as soon as its presence is suspected. In older children also i his may 
be done at the outset. If a clear fluid is a1 firsl obtained and the 
symptoms do no1 retrograde within a short time, the needle should 



666 DISEASES OF THE BESPIBATOBY SYSTEM. 

be again introduced to determine whether the fluid has remained 
serous. It is frequently found to be purulent although no infection 
has occurred as a result of the first puncture. With ordinary clean- 
liness, the possibility of infecting a serous effusion in the chest and 
thereby causing it to become purulent is very slight. Purulent effu- 
sion appearing after the first exploratory puncture has shown the 
effusion to be serous, may be due to two causes : either to continuance 
of the pleuritic inflammation, or to the fact that if the infant or child 
has lain quietly in bed the purulent elements of the effusion have 
gravitated to the lower portion of the chest, leaving a clear serum 
above at the level of the puncture. 

Prognosis. — The prognosis of pleurisy with effusion and of em- 
pyema in infants and children is good. If treated in the proper 
manner, it is not more serious than the original causal affection. In 
private practice, the patient being under constant supervision of the 
physician, the outlook is very good. An effusion can be discovered 
early and the patient relieved. In hospital practice the results are 
still good if the cases are simple and come under treatment before 
systemic infection has taken place. In my service of 120 cases of all 
kinds, there were 20 deaths, 4 of which occurred from one to five days 
after operation. Sepsis had been present before operation and caused 
the fatal issue. The septic cases therefore give an unfavorable prog- 
nosis, as do also those of a tuberculous nature. In the latter, as in 
other forms of tuberculosis in children, the outlook is better than in 
the adult and recoveries are not infrequent. 

Of the 20 cases of death after operation for empyema, broncho- 
pneumonia, either persistent or recurrent, caused the fatal issue in 11, 
general sepsis in 2, marasmus and ulcer of the duodenum in 1, and 
cerebral embolism in 2. A complicating pericarditis of a suppura- 
tive nature may cause death. It is not always possible to diagnose 
this condition during life. The complication most to be feared in 
empyema is a bronchopneumonia involving either lung. In many 
cases the bronchopneumonia is present at the time of operation, or it 
may come on a week or two afterward during apparent convalescence. 

The prognosis of tuberculous empyema is not so unfavorable in 
children as in the adult. In the former, empyema of a tuberculous 
nature, like other forms of tuberculosis, may with skilful management 
make an apparent recovery, though with marked deformities of the 
chest-wall. In this form of empyema the pleura is thickened, bind- 
ing down the lung and thus preventing expansion. Extensive rib 
resections thus become necessary in order to close up the suppurating 
cavity left by the unexpanded lung. 

Treatment. — If on exploratory puncture a serous exudate which 
only partly fills the pleural cavity is found, the expectant plan is fol- 



DISEASES OF THE PLEUEA. 667 

lowed. The bowels are kept open with an enema or a saline cathartic 
is administered daily. For this purpose a saline enema, or in older 
children a teaspoonful of Carlsbad salts in warm water mixed with 
milk is efficient. Local vesication is not needed nor is it advisable. 
The effusion is absorbed if the patients are kept quiet and the diet is 
easily assimilable. Citrate of potassium in grain v (0.3) doses every 
three hours may be given to older children. If the fluid increases in 
quantity, fills up the chest, causes dyspnoea or pressure symptoms, and 
is serous in character, the chest should be aspirated. 

The best form of aspirator for the practitioner is the Potain. The 
patient is aspirated in the sitting posture. The chest-wall having 
been cleansed, the needle is introduced in the posterior axillary line 
toward the lower third of the chest cavity. It is not withdrawn until 
the flow has ceased or the lung can be felt against the needle in the 
pleural cavity. As soon as this occurs the needle is withdrawn and 
the puncture opening covered with a piece of iodoformized gauze. It 
sometimes happens that there are signs that the chest is filled with 
fluid and yet very little flows into the instrument. In such cases the 
needle should be withdrawn and introduced into the chest-wall at 
another point. The coughing attack which occurs during aspiration 
will subside on the patient's taking the recumbent posture. If the 
chest is quite full of fluid, it is well not to empty it entirely. Some- 
times alarming syncope with other signs of cardiac weakness, such as 
cyanosis, has supervened. If a limited quantity of fluid is removed, 
the absorption of the rest will follow rapidly. 

A daily saline cathartic is given ; the patient is kept quiet and 
allowed a nutritious and easily assimilable diet. The administration 
of salicylate of sodium may hasten absorption, especially in cases in 
which there is a rheumatic history. If there is pain or a harassing 
cough, small doses of codeine should be given. 

Empyema. — When the presence of pus in the chest is once estab- 
lished, it is imperative that it be evacuated with the least possible 
delay. In infants and children it is not advisable to temporize by 
first performing aspiration. Retention of even a limited quantity 
of purulent exudate in the pleural cavity not only leads to emaciation 
and physical weakness as a result of continued fever, but general 
sepsis may also result. Aspiration is not efficient, and is to-day prac- 
tically abandoned as a mode of treatment. The physician may either 
incise the intercostal space or resect a rib to obtain drainage. 

Simple incision in the intercostal space is efficient in many cases 
of empyema occurring in the first eighteen months o( life. In these 
frail patients, excision of the rib has been sometimes accompanied 
by discouraging results. 

The greatesl number o( deaths after any operative procedure for 



668 



DISEASES OE THE EESPIEATOEY SYSTEM. 



the relief of empyema occur in children under the age of eighteen 
months. The strength of the patient should be supported as much as 
possible. A general anesthetic is not necessary for patients under 
this age. Bronchitis and pneumonia very frequently result from 
the general use of anesthetics in young patients. Local anaesthesia 

Fig. 149. 




r^ * 




Empyema, site of incision in line with the angle of the scapula. 



is all that is needed. Ethyl chloride in tubes is efficient. The sur- 
face of the chest is carefully cleansed with soap and water, alcohol, 
ether, and sublimate. An incision two inches long or thereabouts 
is made obliquely in the tissues over the intercostal space. The 
space in which a needle has been previously introduced and pus 



DISEASES OE THE FLEURA. 



669 



found is chosen. The exploring-needle is always introduced just 
before operation. Frequently, although pus has been withdrawn from 
the chest, at a second aspiration none can be found. The theory is 
that either there was a small localized collection of pus at the first 
point of aspiration, or that the needle entered a bronchus and with- 
drew secretion collected there. 

On the right side the incision should not be too low, else a tube 
cannot be retained in the chest on account of the high position of the 
diaphragm. The seventh or the eighth space in the posterior axillary 

Fig. 150. 




Exs^ction of rib for empyema on the right side. Shows the resulting deformity. Five 
weeks after operation. Child, four years of age. 



line is the best location if pus is present at this point (Fig. 149). 
On the left side, incisions should not be made too far forward, else 
the drainage-tube may impinge against the pericardium. 

The superficial tissues having been incised, the intercostal muscle 
is incised, the operator keeping as nearly as possible in the median 
line of the intercostal space and avoiding the lower border of the 
upper rib, yet not cutting too close to the lower rib. When the 
vicinity of the costal pleura is reached, a closed dressing-forceps is 
introduced into the pleural cavity and opened to widen the puncture. 
A small drainage-tube or two small tilbes are placed in the pleural 



670 DISEASES OF THE EESPIRATORY SYSTEM. 

cavity and prevented from falling into the pleural space by safety- 
pins passed through them at the distal ends. The pus is not evac- 
uated at the time of operation. The sudden evacuation of fluid which 
has been retained in the chest for a long time is apt to cause untoward 
syncopal symptoms. Gibson has made the excellent suggestion that 
as soon as the pleura is opened the drainage-tube should be quickly 
introduced into the chest, the gauze dressings applied, and the pus 
allowed to escape gradually into the dressings. The dressings consist 
of a pad of gauze around the tubes, covered by a dry sterilized gauze 
dressing which is renewed every day. The chest should not be irri- 
gated. Xo instrument should be introduced into the chest cavity to 
loosen adhesions. 

The whole operation is extremely simple, and should not occupy 
more than a few minutes. Children under five years, and even older 
children may be treated by this method. In the older subjects, how- 
ever, the chest-wall is not so resilient ; there are adhesions, and if 
they are numerous and clots are abundant in the exudate a subsequent 
excision of the rib may be necessary. On the other hand, the main 
object of the practitioner in these cases is to evacuate the pus, and 
incision will accomplish this quite as well as the other operation. If 
subsequently more drainage is needed, the patient will be stronger 
and better able to stand the more serious procedure. 

Incision is therefore the practitioner's operation even in older 
children, with whom anaesthesia must, however, be used. Chloro- 
form is easily taken ; very little need be used. As soon as the skin 
incision has been made, anaesthesia should be suspended. 

Excision of the rib is best performed in children above the age 
of eighteen months, unless there is a contraindication. Severe pneu- 
monia, high fever, cardiac weakness, acute pericarditis or endocar- 
ditis, as complications, are contraindications. In such cases incision 
alone is performed. The rib is excised in the usual way, taking two 
or three centimetres of rib subperiosteally and incising in the mid- 
line of the posterior layer of periosteum to enter the pleural cavity. 
The finger is not inserted into the pleura to loosen adhesions. After 
the pleura is opened, double drainage-tubes are introduced by Gibson's 
method, as in the operation of simple incision. 

Sinus. — After incision or resection of the rib, a suppurating sinus 
may remain for months. If a probe introduced into a sinus of this 
kind impinges against callus or denuded bone, a so-called secondary 
operation is necessary to take out the denuded rib or callus. This 
involves a difficult surgical procedure, which it is not necessary to 
describe here. A sinus of this form will not close until the bone is 
removed. Temporizing only subjects the patient to the dangers of 
prolonged suppuration (amyloid degeneration). 



DISEASES OF THE PLEURA. 



071 



Adhesions Binding Down the Lung. — There is another class of 
cases in which a large amount of fibrin has been thrown out on the 
visceral pulmonary pleura. The lung is thus cramped by an envelope 
of thickened pleura and cannot expand. A large suppurating cavity 
or a suppurating sinus is left between the pulmonary and costal 
pleura. This cavity must be made to close. In such cases the pa- 
tients are allowed to be up and about. They are taught to blow 
colored fluids from one bottle to another in the way described by 
James, of New York (Fig. 151). Two bottles of equal size, each 
half filled with the fluid, are used. In simple cases this method is 
very efficient; in others it is of no avail. The operation of taking 
out two or more ribs with the intervening pleura must then be per- 
formed. In other cases a more extensive operation — the so-called 



Fig. 151. 




James' apparatus for expanding the lungs in empyema 



Estlander, in which large pieces of several ribs are excised with the 
intervening costal pleura — is necessary. If the lung is firmly bound 
down by a coating of fibrin, the chest-wall must be opened by reflect- 
ing a flap of several ribs and the soft parts. The pleura is peeled 
off the lung according to the method of Delorme. The lung expands, 
the costal flap is sewn back in its place, and the chest sinus is in time 
closed as a natural consequence. 

The question of irrigating the pleural cavity in the treatment of 
empyema after operation has been much discussed. As a rule, if 
the temperature drops after operation and remains low, and the dis- 
charge is not fetid, no irrigation is indicated. If, however, there are 
rises of temperature after operation, with a prof use or fetid discharge, 
the chest should be irrigated once daily with normal salt solution. 

Bilateral Empyema. — The treatment of bilateral empyema will 
tax the judgment of the physician. One side, preferably the Left in 



672 DISEASES OF THE BESPIBATORY SYSTEM. 

order to relieve the heart, is first operated on by incision or rib exsec- 
tion; the other side is aspirated, and again aspirated if the fluid or 
pus accumulates. After a week adhesions will have formed on the 
operated side, and the strength of the patient will warrant interfer- 
ence on the opposite side. When this is accomplished, the opening 
on the operated side must be closed by some device, such as a pad of 
gauze on which is placed rubber tissue covering, and the second side 
may be operated on by rib exsection or incision. 

I have followed this method in two cases without serious accident. 
The interval of a few days between the operations is sufficient to allow 
adhesions to form on the operated side to such an extent that, when 
the second side is opened, the lung of the side first operated on does 
not collapse. If the sides are operated on simultaneously, the con- 
sequent partial collapse of both lungs causes marked symptoms of 
asphyxia. 

Hemorrhagic Pleurisy. — Simple hemorrhagic pleurisy is not un- 
common. It is seen in pleurisy following simple pneumonia, influenza, 
the exanthemata, and in infants or children in whom there is a ten- 
dency to scorbutus. Cases which appear to be rheumatic have been 
published (Starck). The hemorrhagic form of pleurisy with effu- 
sion may occur in very young infants (Lewin, eleven months) or in 
young children. I have met a number of cases in children who sub- 
sequently made a complete recovery, and in whom I could find no 
tuberculous tendencies. The prognosis in this form of pleurisy is 
therefore much better in children than in adults. In the latter a 
hemorrhagic pleurisy is frequently indicative of a tuberculous factor 
in the etiology. 

Hemorrhagic Empyema. — Hemorrhagic empyema is also not un- 
common in infants and children. During the past year I have met 
four cases in which there was a hemorrhagic exudate. In one case 
the child was pale, though not emaciated. There may have been a 
scorbutic element. In another case, in a boy, no such etiology was 
indicated. In a third case, in a girl, the child was much reduced in 
health. In three cases the hemorrhagic discharge persisted for days 
after the chest was opened and streptococci were found in the exu- 
date. In one case the discharging pus was for weeks tinged with 
blood. In none of the cases were tubercle bacilli found in the pleu- 
ritic exudate. Three of the cases made a very good recovery. In 
these cases also I am inclined to believe that tuberculosis is not always 
an etiological factor. 

Subphrenic Abscess or Pyopneumothorax Subphrenicus. — The 
positive diagnosis of subphrenic abscess should be made with reserve, 
because no pathognomonic symptom or physical sign of the disease is 
known. It is a very valuable fact that in 50 per cent, of the cases 



DISEASES OF THE PLEURA. 673 

thus far recorded, the abscesses have contained gas or air. The con- 
dition is rare (Maydl) in adults and more so in infants and children. 
The abscess is situated beneath the diaphragm, and between that 
organ and the liver. It pushes the diaphragm upward, and may thus 
encroach on the pleural space and simulate a real pyopneumothorax. 
An area in the lower part of the thorax, which may give tympanitic 
resonance or tympanitic dulness from the second, third, or fourth 
rib downward, is thus caused. This resonance may even include the 
liver, which is displaced downward. Over the region of tympanitic 
resonance, especially posteriorly, the normal vesicular breathing is 
absent on expiration and present over the area on deep inspiration. 

It is a peculiarity of the condition that there may be amphoric 
breathing and metallic tinkle over the area, while anteriorly, just 
above it, from the second to the fourth rib, there is a sharp transition 
and normal breathing is heard. Behind, however, on deep inspira- 
tion, even over the region of tympanitic resonance, normal breathing 
may be heard over the lower part of the chest. Over the situation of 
the abscess the metallic tinkle and succussion-sounds may also be 
heard. As has been stated, the liver may be displaced downward, 
crepitations are heard anteriorly over the liver (perihepatitis), or it 
may be impossible on account of intestinal conditions to make out the 
lower border of the liver. I have seen a subphrenic abscess on the 
left side displace the left lobe of the liver and the spleen downward. 
The heart is not displaced inward if the abscess is on the left side, 
but if displaced at all, is so in an upward direction. The lower 
thorax region may show no abnormalities to inspection, while the 
upper abdominal region may be normal, painful to pressure, or slightly 
eedematous. 

Diagnosis and Treatment.- — Exploratory puncture is resorted to in 
all of these cases. Diagnosis will be aided if the fluid obtained con- 
tains, in addition to pus, elements which denote the origin of the 
abscess, such as food particles, faeces, histological debris or pigment 
from the liver. In many cases the liver suffers from the vicinity of 
the abscess. 

The treatment is surgical. 



43 



SECTION IX. 

DISEASES OF THE CIRCULATORY SYSTEM. 

DISEASES OF THE PERICARDIUM. 

Pericarditis. — Pericarditis is an inflammation of the pericardium 
due to infection, which may take place through the blood- or lymph- 
channels or may occur through contiguity to infected areas in neigh- 
boring structures. The existence of primary pericarditis or so-called 
idiopathic pericarditis apart from rheumatism or infection is a matter 
of doubt. It is therefore to be regarded as secondary to other condi- 
tions or the result of direct systemic infection. 

Occurrence. — Pericarditis occurs in foetal life (Billard, Tardieu, 
Heiter) ; Bednar describes cases in newly born infants ; it is common 
in infancy and childhood. Steffen and Baginsky describe a number 
of cases occurring in infancy. Of 66 cases of pericarditis in chil- 
dren, Baginsky found 20 to occur during the first year of life. The 
next greatest frequency was between the first and the fifth year. 

Etiology. — The majority of cases occur as complications of acute 
articular rheumatism (Steffen, Friedreich, Bauer, Baginsky), with 
or without chorea. Tuberculosis and pleuropneumonia rank next as 
etiological factors. Pericarditis occurs in the exanthemata, scarlet 
fever, measles, and typhoid fever. It may complicate pertussis, 
diarrhoeal disorders, otitis, meningitis, peritonitis, mediastinitis, or 
any septic process, such as osteomyelitis. It is also in the newly 
born infant concomitant with septic conditions. Finally, trauma- 
tism may cause pericarditis. The tuberculous form is uncommon 
before the fifth year of life (See). 

Bacteriology. — The pyogenic bacteria most frequently found in 
pericardial effusions, and which play an etiological role, are the 
pyogenic streptococci and staphylococci, the pneumococcus of Frankel 
and Weichselbaum, the tubercle bacillus, the Friedlander bacillus, the 
Bacterium coli, and the Bacillus pyocyaneus (Ernst). 

Forms. — There are the same forms of pericarditis in children as 
in the adult subject. The forms with effusions have, however, a 
tendency to become purulent, especially in infants and younger chil- 
dren (Baginsky). In these patients, the fibrinous forms result in 
localized or general adhesions of the two layers of the pericardium 
'and in partial or complete obliteration of the pericardial sac (adher- 
ent pericardium). 

674 



DISEASES OF TEE PEBICARDIUM. 675 

Morbid Anatomy. — \n the mildest forms, there is only a loss of 
lustre to the serosa in circumscribed or diffuse areas. The fluid in 
the pericardial sac may be increased in quantity and may contain 
cellular elements. In other forms, the surface of the pericardium is 
coated with a layer of fibrin of greater or less thickness. The fibrin 
may be in the form of bands or of small villous formations. There 
may be minute, hemorrhages on the surface (Delafield). In more 
pronounced processes the fibrin is in the form of hemorrhagic tena- 
cious masses forming a thick network of strips or bands (cor villo- 
sum). The quantity of fluid in the sac varies. The fluid may contain 
blood. 

In the first stage of inflammation, the connective tissue of the 
pericardium is infiltrated with lymphoid cells and the vessels are 
filled with blood. After the third day, new vessels appear in the 
fibrinous exudate on the surface. Fibroblasts, spindle-shaped, spher- 
ical, and branching, form a network in this new tissue (Ziegler). 
Granulation tissue and finally new connective tissue replace the fibrin- 
ous exudate, after a period of weeks (productive pericarditis). The 
so-called opaque areas of thickened pericardium, the maculae tendinete 
seen in adults, are rare in children (StefTen). Adhesions, either 
localized or general, may form between the two layers of the pericar- 
dial sac, causing its partial or complete obliteration. 

Tuberculous forms of pericarditis may occur as miliary infiltra- 
tion of the parietal and visceral layers of the pericardium. There 
may be serous, serofibrinous, purulent, or hemorrhagic exudate in the 
sac, or gray cheesy nodules of tubercle tissue may be present in the 
epicardial and subpericardial tissue (Ziegler, Baginsky). 

Myocarditis, circumscribed or general, may occur in all forms of 
pericarditis. The adhesive forms are complicated with myocarditis. 

Symptoms. — Pericarditis in children manifests itself by rational 
symptoms and physical signs. 

Rational Symptoms. — At the bedside, the symptoms of the differ- 
ent forms of pericarditis cannot be divided into classes. Some of the 
fibrinous or dry forms run an insidious course without giving any 
marked symptoms of the disease. On the other hand, large effusions 
may make their appearance without any previous rational symptoms 
which are characteristic. This is the case in the forms of pericarditis 
in infants and children, which occur in septic conditions, in pneu- 
monia, empyema, and in the exanthemata. If attention has been 
drawn to the heart, it will be found that certain symptoms may be 
traced to the inflammatory process in the pericardium. It* £he pa- 
tients have been suffering from endocarditis of rheumatic origin. 
empyema, or one of the exanthemata, they show the symptoms of 
grave cardiac disease. They have an anxious facial expression, with 



676 DISEASES OF THE CIRCULATORY SYSTEM. 

marked pallor and cyanosis of the lips. They do not, as a rule, com- 
plain of pain. The respirations are markedly increased, as is also 
the pulse. Older children may complain of pain or uneasiness in 
the epigastrium. They also show marked dyspnoea and orthopnoea. 
In infants there are signs of pain on breathing. In some of the 
fibrinous forms there is fever, but dry forms of pericarditis may run 
their entire course without it. The purulent forms give a remittent 
temperature-curve. The pulse is rapid, varying from 120 to 150. 
In the forms with effusion, the pulse is irregular. If myocarditis is 
present, the pulse is irregular and persistently high, and there is an 
accompanying increase in the number of respirations. There is no 
case on record in which the diagnosis of mediastinopericarditis has 
been made in a child during life and confirmed at autopsy, nor does 
the so-called pulsus paradoxus give any assistance, since it is present 
in other conditions in childhood (Steffen). 

Physical Signs. — In pericarditis there are the physical signs of the 
dry plastic forms and the forms with effusion into the sac. The 
signs of the dry pericarditis and those of the first stage of that with 
effusion are practically identical and may be considered together. 

Inspection.- — -In dry plastic pericarditis and the first stage of peri- 
carditis with effusion there may be no signs to be detected by inspec- 
tion. There may be an increased impulse, apparent to the eye, over 
the whole cardiac area to the left. When effusion takes place, little 
or no pulsation can be made out over the cardiac area when the patient 
is in the recumbent position. There may be distinct bulging of the 
cardiac area, varying with the amount of fluid present. 'No localized 
apex impulse is visible when the amounts of fluid are large. There 
may instead be a diffuse pulsation over the area of the apex and toward 
the sternum. 

Palpation. — In dry pericarditis, and in the first stage of pericar- 
ditis with effusion, there is a friction fremitus felt over the areas 
in which the friction murmur is heard. This may be at the apex, 
at the base, or along the right ventricle close to the left border of the 
sternum. 

The Apex-beat or Impulse and Its Relations to the Chest-wall in 
Pericarditis with Effusion, — As effusion takes place, it is indicated 
by certain physical signs relative to the heart apex, and by the line of 
dulness to the left. Investigations have shown that, when the patient 
is in the recumbent posture, pericardial effusion first collects at the 
base of the heart around the great vessels. It next collects over the 
anterior surface and in the anterior-inferior cul-de-sac of the peri- 
cardium ( Voinitch) . 

When the patient is recumbent the effusion does not necessarily 
push up the apex-beat. On the contrary, it separates the heart from 



DISEASES OF TEE PERICARDIUM. 67^ 

the anterior chest-wall. In moderate effusion the apex-heat may still 
be felt in the normal position. As the effusion increases, the apex- 
beat recedes and becomes less discernible and more diffuse, and in 
large effusion may disappear. This is especially the case if there is 
dilatation of the heart or adhesions at the apex. When the effusion is 
again absorbed, the apex-beat becomes evident in the former situation. 

When the patient is sitting, the pericardial effusion collect- be- 
neath and behind the heart, and, if the heart is not enlarged or held 
down by adhesions, the apex-beat may at first be displaced upviard, 
and will be felt above and to the outside of its normal position. These 
facts will explain the failure in certain cases of pericarditis to obtain 
the displacement of the apex-beat upward. In one of my cases, a 
boy of six years, suffering from chorea, endocarditis, dilated heart, 
and pericarditis, the apex-beat was observed in the beginning of the 
stage of effusion to be located in the sixth space, slightly outside the 
nipple line. Effusion having occurred, the apex-beat could still be 
observed in its former locality, but the area of absolute dulness indi- 
cating effusion extended beyond the apex, four cubic centimetres to 
the left of the mammillary line. The effusion disappeared and the 
apex then corresponded with the line of dulness of the left ventricle. 

Percussion. — In dry fibrinous pericarditis, and in the dry stage 
of pericarditis with effusion, there is no increase in the area of cardiac 
dulness directly traceable to the disease. If there is a slight dilata- 
tion or relaxation of the ventricle due to myocarditic complication, the 
normal precordial dulness may be more distinct. 

The effusion must have a bulk of 40-60 grammes (1-J to 2 fluid- 
ounces) before definite signs of its presence can be obtained. 

In young children, the area of dulness due to pericardial effusion 
does not have the triangular shape seen in adults. The position of the 
heart is more horizontal and its shape is retained by the distended sac. 
Thus, to the left, the dulness may extend in a curved line outside the 
situation of the nipple. Superiorly, it may extend as high as the first 
rib. It then extends in an almost horizontal line two or more centi- 
metres to the right of the sternum (Fig. 152). The line of dulness to 
the right of the sternum then extends downward in an almost vertical 
line to the liver at the sixth space or Rotch's space (Steffen, Baginskv. 
Ausset). These facts are very important in differentiating dulness 
resulting from pericardial effusion from dulness due to other causes. 
Even in moderate effusion there is resistance to the percussing finger. 
If the patient's position is changed from the recumbent to the sitting 
posture, the heart falls forward, the pericardia] sac is distended, and 
the dulness to the Lefl may come more toward the mammillary line 
and, to tho right, toward the sternum (Baginsky). Percussion is 
painful in pericardia] disease and the examiner should bear this in 
mind. 



678 



DISEASES OF THE CIRCULATORY SYSTEM. 



Auscultation. — The friction sound is diagnostic in dry plastic 
pericarditis and in the first stage of pericarditis with effusion. It 
mar, at the outset, be heard at the apex (Steffen), but is also heard 
to the left, of the sternum over the base, or below, to the left of the 
sternum, over the fourth or fifth space. Steffen finds it in children, 
at first, most frequently at the apex. The friction may be heard on 
systole or diastole, or on systole only. It may or may not accom- 
pany the valvular sounds. It is of very limited distribution, is not 

Fig. 152. 




Pericardial area of dulness due to effusion in boy, six years of age. Chorea, endo- 
carditis, and pericarditis ; x, apex-beat before effusion ; o o o o, friction murmur ; outer 
curved line shows general shape of distended pericardial sac. 



conducted, and is of a fine crepitant quality or has a shifting, rubbing, 
rasping or clicking sound. 

In the case of a boy suffering from recurrent chorea and pericar- 
ditis, there was a loud scraping friction at the apex with murmurs of 
mitral and aortic regurgitation. I was able in this case to confirm 
the statement of Walsh, that a loud pericardial friction may rarely 
be heard behind, between the scapulae, to the left of the spine. The 
friction may for the first day or two be of a crepitant quality and 
then acquire a rubbing quality. I observed this change in a child 
four years of age. The patient suffered from dilatation of the left 
ventricle with mitral insufficiency and stenosis with pericarditis. 
The friction for two days was crepitant in quality and just audible 



DISEASES OF THE PERICARDIUM. 079 

over the fourth and fifth spaces, to the left of the left border of the 
sternum and then acquired a loud rubbing quality. The murmur is 
sometimes very evanescent or may disappear or reappear at short 
intervals. The sounds may be intensified by causing the patient to 
lean forward. When effusion appears, the friction sounds may en- 
tirely disappear, or may be heard only in areas around the great 
vessels or indistinctly over the prsecordium. A knowledge of these 
facts is important in making a diagnosis of fluid in the pericardial 
sac. The friction sounds may reappear on absorption of fluid. 

Pleuropericardial friction sounds are rough or fine sounds ob- 
tained in children as in adults with the respiratory movements of the 
lung. They are intensified on expiration and disappear when respi- 
ration is momentarily suspended. They may be heard over any part 
of the prsecordium. They are caused by the rubbing of the inflamed 
pleura and pericardium against each other. This friction is limited 
to one edge of the cardiac area, generally the left, and is sometimes 
heard in the back, on the left side. 

Diagnosis. — The diagnosis of pericarditis can only be made from 
the physical signs. In dry plastic pericarditis and the first stages of 
pericarditis with effusion, the friction sound is the diagnostic sign. 
If a pericardial friction is once obtained, careful watch should be 
kept for the appearance of fluid. It is not possible at the outset to 
differentiate a dry pericarditis which will remain as such, from the 
first stage of a pericarditis with effusion. 

In the stage of effusion, small amounts of fluid will sometimes 
escape diagnosis. This is likely to occur if a process such as empyema 
is in progress on the left side. The first stage of a pericarditis may 
escape diagnosis if the friction sound is evanescent. If the effusion 
appears in considerable quantity over the great vessels, percussion is 
made in this region, especially to the right side of the sternum at the 
level of the second or third space, for an increase in dulness due to a 
distended pericardium. Absence of dulness in this region across the 
sternum and for a few centimetres to the right of the right border is 
presumptive evidence against the presence of any considerable effu- 
sion. If dulness exists to the right of the sternum, low down only 
on a level of the fourth interspace, there is probably no pericardial 
effusion, but, instead, dilatation of the right ventricle. 

Differential Localization by Percussion- of Pleural and Pericar- 
dial Effusions. — In cases in which pericardial effusion is very large 
or in which there is pleural effusion into the left side of the chest, a 
question may arise as to whether there is a simple pleural effusion, 
general or localized, pericardial effusion, or both. Percussion along 
the sternum will in simple left pleural effusion easily mark out the 
displaced left pleural fold. If there are Large amounts of fluid, the 



680 DISEASES OF THE CIECULATOEY SYSTEM. 

fold of the left pleura will be found to be distinctly displaced toward 
the right border of the sternum. The pleural line will not pass 
beyond the border of the sternum to the right. If large pericardial 
effusion is present, the dull note of the effusion extends beyond the 
right border of the sternum, especially at Botch's space. In left 
pleuritic effusion the apex of the heart is found by auscultation to 
be distinctly displaced to a situation beneath the sternum, while in 
pericarditis it will at first be found to be in the normal position and 
subsequently to disappear or to be displaced upward and outward. 

Prognosis. — The prognosis of rheumatic pericarditis is good. The 
purulent forms of pericarditis are in the great majority of cases fatal, 
especially in very young infants. In older children, I have seen cases 
of purulent pericarditis, clue to infection from a concurrent pneu- 
monia or empyema, recover with timely pericardotomy. The septic 
forms of purulent pericarditis, complicating sepsis of the newly born 
and forms of osteomyelitis, are fatal. 

Treatment. — The treatment of the dry fibrinous forms of pericar- 
ditis is limited to the relief of the pain and the treatment of the 
primary condition, rheumatism. The pain is best relieved by the 
administration of mild opiates. Codeine in small doses is efficient in 
many cases. I am not in favor of blistering the precordial region in 
children, or of applying a seton, as is done in adults. If the heart is 
tumultuous, small doses of digitalis in the tincture form and the con- 
stant application of an ice-bag over the precordial region are the most 
effective remedies. Some authors believe that the ice-bag is also a 
very powerful means of limiting the inflammation. In rheumatic 
or choreic cases the salicylate of sodium is given, or if this disagrees 
with the patient, the ordinary bicarbonate of sodium in doses of 
grains x (6.5) three or four times daily. Perfect rest in bed, long 
after the process has run its course, is indicated, on account of the ill 
effects of strain on the heart affected by myocarditic changes which 
are undoubtedly present in many of the cases. 

When effusion has taken place, the question of the advisability 
of puncturing and exploring the pericardium always arises. It is 
very difficult to choose the proper time for entering the pericardium. 
I have had a number of cases of pericarditis with effusion recover 
without being subjected to what is at best a hazardous procedure. I 
temporize until the orthopncea and cyanosis are extreme and evidences 
of pressure are marked. Too much importance should not be attached 
to ordinary symptoms. On the other hand, if the temperature is high 
and daily remits to near the normal, there may be a purulent effusion. 
If after a reasonable length of time the patient steadily loses ground 
and the signs of effusion are marked, the pericardium should be 
entered to determine the character of the exudate. If it is serous. 



DISEASES OF TEE PERICARDIUM. 08 1 

ordinary aspiration will suffice, but if purulent, the operation of peri- 
cardotomy should be performed. Pericardial puncture or incision is 
performed in the same manner as in adults. 

It may be remarked that Henoch has never punctured the peri- 
cardium. In one of his cases, postmortem examination showed small 
sacculated purulent collections of fluid which could hardly have been 
evacuated by a single puncture. I found a similar condition post- 
mortem in a case in which puncture of the pericardium was under- 
taken, and resulted in puncture of the heart. 

Morse, on the other hand, advocates early puncture of the 
pericardium. 

Adherent Pericardium. — Adherent pericardium is an agglutina- 
tion, localized or complete, of the visceral and parietal walls of the 
pericardial sac which becomes partly or completely obliterated. 

Etiology. — The condition follows either a dry plastic pericarditis 
or a pericarditis with effusion, in the stage of absorption. In the 
latter case, if the absorption of fluid has been observed and the redux 
friction-sound obtained, adhesion of the pericardium may be sus- 
pected from certain signs; otherwise, diagnosis even within probable 
limits would in many cases be an impossibility. Infants and chil- 
dren who have withstood an attack of pericarditis, especially of the 
rheumatic form, are very prone to contract this form of pericarditis. 
In most cases it causes myocarditis of a progressive type ; hence the 
importance of understanding the condition. Hypertrophy of the 
heart, atrophy of the heart, or dilatation of that organ may accom- 
pany adherence of the pericardium. 

Symptoms. — The symptoms, especially in the rheumatic cases, 
develop late in the disease when myocarditis supervenes. The con- 
dition may prove fatal by progressive affection of the cardiac muscle. 
One of my cases, of rheumatic origin, showed postmortem no valvular 
lesion. There were complete obliteration of the sac and extreme dila- 
tation. The symptoms are at first negative. There may be a fric- 
tion sound or a roughening of the cardiac sounds at the base. There 
is in some cases a drawing inward of the apex area of the chest at the 
xiphoid cartilage. A wave-like undulation of the cardiac area with 
an increase of cardiac dulness is sometimes found. There may be 
persistent asystole not controlled by digitalis (See). In my eases 
there were angina, a persistently high pulse with an increase in the 
number of respirations, and in the last stages, all the symptoms of 
non-compensatory dilatation of the ventricle which are seen in val- 
vular disease. There may be a mitral systolic murmur simulating 
that seen in valvular disease. In spite of all these symptoms, ir is 
rarely possible to make a positive diagnosis during life. 



682 DISEASES OF THE CIECULATOBY SYSTEM. 

DISEASES OF THE HEART. 

The height of the heart and of the great vessels in children does 
not differ after the third year from that of the adult. The ratio of 
the transverse to the sagittal diameter of the chest in newborn infants 
is 2 to 1, while in adults it is 3 to 1. This fact should not be forgotten 
in estimating the size of the heart in infants and children. What in 
an adult might appear to be a large heart, would be normal to the 
infant or young child. 

Position. — In the first year of life the long axis of the heart is 
more horizontal than in later childhood or in adult life (Eauchfuss). 
At the third year, the position of the heart is practically that found 
in the adult (Dwight). 

As the child becomes older the heart assumes more nearly the 
vertical position, and in older children the apex-beat may be found 
0.75 to 1 centimetre within the mammillary line. The situation of 
the mammillary line is variable in young children ; the nipple is over 
the fourth rib, but further removed from the midsternal line than in 
older children on account of the great transverse as compared to the 
longitudinal diameter of the thorax. In older children the heart 
areas closely resemble those in the adult. In infants and young chil- 
dren there are certain variations from the adult condition which 
should be borne in mind. 

Size. — The heart is relatively larger in the infant than in the 
adult, having 0.89 per cent, of the body weight in the newborn infant, 
while in the adult it has only 0.52 per cent. (Vierordt). 

Apex-beat. — The apex-beat in the newborn infant may be felt 
higher than in the adult. On account of the greater breadth of heart 
as compared with that of the chest the apex is external to the mammik 
lary line. Steffen says that normally the apex-beat may be found 1 
centimetre external to the mammillary line, or in the mammillary 
line, or internal to the mammillary line. The apex-beat in infants 
and children is in the fifth space. 

Inspection. — Inspection shows in some cases an undulatory move- 
ment over the whole cardiac region. This is normal as long as it is 
confined to the left of the sternum, but an undulatory movement to 
the right of the sternum is probably indicative of dilatation of the 
right ventricle with or without hypertrophy. In rachitis the cardiac 
region is sometimes unduly prominent. This condition must be dis- 
tinguished from the more pronounced fulness in the praecordium 
occurring in cases of hypertrophy or of pericardial effusion. 

Children who in early childhood have suffered from cardiac dis- 
ease with dilatation and hypertrophy of the left ventricle may show 
a marked prominence of the prsecordium. 



DISEASES OF THE HEART. 683 

The apex-beat should not be mistaken for an apparent apex-beat 
which is sometimes seen in young children in whom the intercostal 
space to the left of the large cardiac dullness is raised with each pulsa- 
tion of the apex. Percussion in these cases will show the apex to be 
situated elsewhere to the left and downward. In some cases the apex, 
instead of pushing the intercostal space forward, draws it distinctly 
inward. This is in part due to adhesions between the heart, peri- 
cardium, and parts external to the pericardium. When children are 
struggling, the systolic impulse of the heart is seen to be communi- 
cated to both the carotid artery and the jugular vein, the vein getting 
its impulse from its proximity to the artery. The vein may be found 
to be collapsed and the artery to show an impulse on systole. 

Palpation. — The following points may be determined by palpation 
with the tips of the fingers or full palm : 

1. Location of the apex-beat. 

2. Sometimes the location of the left boundary of the heart. 

3. The force of the systole, hypertrophy or dilatation of the heart, 
especially if pulsation is evident to the right of the sternum. 

4. Transposition of the heart to the right. 

5. The closure of the valves of the pulmonary artery in the second 
or third space near the sternum. 

6. Murmurs which cause friction (pericardial) or thrills (endo- 
cardial). 

7. Rhythm of the heart action. 

Auscultation. — In infancy the muscular quality of the first sound 
is not apparent. The heart-sounds have more the character of the 
tick-tack of a watch. The muscular character of the first sound fully 
develops toward the second year of life. All through infancy and 
childhood there is a natural accentuation of the second pulmonic 
sound. Too much importance should not be attached to the accentua- 
tion even if it is marked. 

Percussion. — The percussion of the heart has been the subject of 
much refinement of methods, which only tends to confuse a simple 
matter. The following method will be found suitable for most clin- 
ical purposes : 

The line of demarcation is the midsternal line. All reckonings 
as to the limits of cardiac dulness may be safely made from the mid- 
sternal line, the situation of the mammillary line being variable in 
children. The right border of the sternum is not a good line to 
reckon from, since (lie width of the sternum varies. The recumbent 
posture is preferable in infants; both the recumbent and upright posi- 
tions are suitable in older children. 

Method of Locating the Line of Dulness of the Left Ventricle. — To 
locate the external boundary of the ventricle, we begin to percuss in 



684 



DISEASES OF THE CIBCULATOBY SYSTEM. 



the lines parallel with the second, third, fourth, and fifth ribs toward 
the heart, from the axillary line or the anterior axillary line. To 
percuss from the midsternal line outward does not in children give 
as good results. 

To locate the external border of the right ventricle, we percuss 
along the fourth rib or fourth space toward the sternum from the right 
mammillary line. In young infants a portion of the right auricle 
and ventricle will be found as high as the junction of the second rib 
and the sternum (Symington), but it is an ultra-refinement of per- 

Fig. 153. 




Form of the normal relative cardiac dulness in a child two and one-half years of age. 



cussion to try to make out the projection of this part of the right 
auricle to the right of the sternum. It is found, anatomically, that 
the curve of the auricle to the right of the sternum begins at the third 
space, and is most marked behind the fourth costal cartilage. It is 
sufficient for clinical purposes to make out this most projecting part 
of the heart to the right of and behind the sternum. 

The apex of the heart is generally made out by percussing along 
the fifth rib or fifth space from the antero-lateral axillary line toward 
the midsternal line. The external boundarv of the left ventricle is 



DISEASES OF THE HEART. 685 

in children slightly outside the apex-beat, The area of cardiac dull- 
ness which is absolute and which is uncovered by lung can best be 
made out by percussing from above downward over the cardiac area. 
In children or infants this area cannot be marked out as definitely as 
in the adult. The younger the child or infant, the greater the diffi- 
culty. In infants and children interest centres rather in the apparent 
size of the heart (relative dulness) than in the area uncovered by lung. 
The dulness extends to the right and left of the midsternal line, 
at a level with the fourth rib, as is indicated by the following figures 
compiled from StefFen's tables : 

Infants under one year right v. 4 to 6.5 cm. to right. 

left v. 3.5 to 6.25 cm. to left. 
Children one to two years right v. 4 to 6.5 cm. to right. 

left v. 4 to 7.25 cm. to left. 
Children two to three years right v. 4.5 to 7.5 cm. to right. 

left v. 4.5 to 6.5 cm. to left. 
Children five to six years right v. 5.5 to 7.25 cm. to right. 

left v. 5 to 8.25 cm. to left. 
Children nine to ten years right v. 5.5 to 8.5 cm. to right. 

left v. 5.5 to 8.5 cm. to left. 

Enough has been selected to show that the actual size of the heart 
as obtained by percussion in infants and children is extremely vari- 
able, and the examiner must be guided by the relative size. 

Congenital Heart Disease. — Congenital heart disease may be sus- 
pected from certain physical signs which occur in that condition and 
are in a sense characteristic of it. These are cyanosis, changes in the 
area of cardiac dulness, and the presence of characteristic murmurs. 

Cyanosis. — The cyanosis which is characteristic of congenital heart 
disease does not occur in any of the acquired cardiac lesions. It is 
most common in the congenital forms of pulmonary stenosis of the 
artery, conus, or ostium. On the other hand, it may be absent in 
marked congenital disease, as in deficient ventricular septum and open 
ductus arteriosus. In the latter disease it may appear late in the 
condition, only at intervals, or not at all. It may be absent at birth 
and appear in infancy or childhood. 

Cardiac Dilatation and Hypertrophy. — The presence of a murmur of 
congenital origin does not necessarily presuppose change from the 
normal in the area of cardiac dulness. In fact, a normal cardiac area 
is sometimes evidence of the congenital character of a murmur. 
Hypertrophy of the left ventricle should be present with hypertrophy 
of the right ventricle, and a murmur to indicate open ductus arteri- 
osus. Dilatation of the right ventricle is of value when present with 
a murmur indicating stenosis ai the pulmonary valve. On the other 
hand, marked congenital defects may exist without any change in the 
size of the ventricle. Moreover, if the cardiac area is enlarged and 
the apex impulse weak, congenital disease may be suspected. The 
weak apex impulse indicates dilatation. 



686 DISEASES OF TEE CIECULATOEY SYSTEM. 

Murmurs. — The murmur most characteristic of congenital heart 
disease is a systolic murmur at the situation of the space between the 
second and third costal cartilage to the left of the sternum, and not 
conducted into the arteries of the neck. It is only when there are 
complicated defects that murmurs are conducted into the carotids 
(open ductus arteriosus). 

Foetal endocarditis affecting the tricuspid or mitral valves is rare, 
and therefore murmurs of congenital origin are rare at these valves. 

Diastolic murmurs are, so far as congenital lesions are concerned, 
of theoretical interest only. 

Systolic murmurs, such as those heard in defects of the ventric- 
ular septum, and which cannot be attributed to valvular disease, 
occur at the pulmonic valve?. In these cases the murmur has no 
point of greatest intensity, but is heard not only at the valve, but 
also over the whole prsecordium. The valvular sounds are distinct. 
The most marked congenital defect or disease of the heart may exist 
without any murmur or other physical signs during life. 

In simple pulmonary stenosis, the second pulmonic sound is weak ; 
in cases complicated with open ductus arteriosus and hypertrophy of 
the ventricles, it is accentuated; in cases of pulmonary stenosis and 
deficient ventricular septum, it is either weak or very low. 

Positive Diagnosis Often Impossible. — The diagnosis of the exact 
lesion in congenital heart disease is in many cases impossible. The 
reason for this is easily found in the fact that if the patient lives 
longer than the first year, the lesion is rarely simple, but occurs with 
other congenital defects in the heart. Another cause is the rarity of 
autopsies on uncomplicated cases which have been carefully studied 
during life. Lastly, in complex cases, even if the diagnosis has been 
confirmed at autopsy, it is impossible to say to what degree the lesion 
diagnosed and the other complicating conditions found at autopsy 
have been the cause of the signs and symptoms found during life. 
The physical signs of congenital heart disease vary as the lesion is a 
simple one or is combined with other congenital defects. The follow- 
ing classification of congenital heart disease of developmental or 
foetal endocarditic origin will be found useful in clinical work : 

1. Septum Defects. — Auricular (foramen ovale) ; ventricular. 

2. Pulmonary Artery. — Stenosis of the conus, trunk, or ostium: 
(a) simple cases (before the end of the first year of life) ; (b) com- 
plicated cases with open foramen ovale or ductus arteriosus, defect of 
the ventricular septum, or transposition of the great vessels. 

3. Aortic Valve Stenosis or General Contraction of the Aortic 
System. — The first may be due to developmental defect or to foetal 
endocarditis ; the second, to developmental defect. All aortic condi- 
tions anomalous in character have, so far as is known, not been diag- 
nosed during childhood. 



DISEASES OF TEE HEABT. 



f>H7 



4. Valvular Anomalies. — Valvular anomalies of the semilunar 
valves, due to foetal endocarditis or developmental irregularities are 
of purely scientific interest. 

5. Open Ductus Arteriosus or Botalli. — (a) Simple; (b ) com- 
bined with septum defects or pulmonary stenosis. 

6. Transposition of the Heart and Congenital Anomalies of the 
Pericardium (of purely scientific interest). 

Fig. 154. 




Clubbed fingers of congenital heart disease. Child, six years of age. 

From the above account, which I have modified for practical use 
from the classification of Vierordt, it will be seen that only the con- 
genital anomalies of the auricular ventricular septum, the pulmonary 
artery, and the ductus arteriosus Botalli are of interest to the clinician. 

Stenosis of the Pulmonary Artery, Conus, or Ostium. — This is 
the most common of all congenital heart lesions. If Pound after the 
thirteenth month of life, it is in most cases combined with a con- 
genital deficiency of the septum ventriculorum. RauchfusS found 
a simple stenosis in only 10 per cent, oi' all the published cases. 
Most of the cases are due to foetal endocarditis. 



688 DISEASES OF THE CIBCULATOEY SYSTEM. 

Physical Signs'.— Simple Stenosis.- — Simple stenosis of the artery, 
conus, or ostium, found only before the thirteenth month (Rokitansky) . 

Cyanosis. — Early and congenital cyanosis and signs of venous 
stasis, such as clubbed extremities of the fingers, even in young in- 
fants. In cases which are met in later life the clubbing of the ex- 
tremities of the fingers and cyanosis of the finger-tips are marked. 

Blood. — The blood shows so-called polycythemia. The number 
of erythrocytes is increased above the normal, being 7 to 9,000,000 to 
the cubic millimetre, as shown by some of my cases. The hemo- 
globin index is also increased. The white blood-cells are normal in 
number. The increase in erythrocytes is regarded as an evidence of 
compensatory over-production caused by the increased need of oxygen 
on part of the tissues in the presence of cyanosis. 

Murmur. — A systolic murmur heard with greatest intensity at 
the situation of the pulmonary valve to the left of the sternum, be- 
tween the second and third costal cartilages, and not conducted into 
the carotids. A weakened second sound at the pulmonary valve; 
dilatation of the right ventricle. 

Simple stenosis is found in infants, but is rare. In most cases 
there are also present congenital defect of the ventricular septum, 
open ductus arteriosus, tricuspid changes, or the aorta arises from 
the right ventricle or both ventricles. The following facts should be 
kept in mind in the diagnosis of cases occurring after the thirteenth 
month of life: 

If the above signs are present with a weakened second pulmonic 
sound, there being absolutely no conduction of the murmur into the 
carotids, it may be assumed that there is a pulmonary stenosis with 
an open foramen ovale. 

Conduction of the murmur into the arteries of the neck, with a 
very distinct though not accentuated second pulmonic sound, points 
to the presence of a septum defect with a pulmonary stenosis. 

An accentuated second pulmonic sound with conduction of a 
murmur of a loud buzzing character into the subclavian and carotids, 
and a hypertrophy of the right and also of the left ventricle, will sup- 
port the theory of a pulmonary stenosis with a patency of the ductus 
arteriosus (Hochsinger). In these cases of open ductus arteriosus 
there is a thrill and a distinctly defined area of dulness in the second 
space to the left of the sternum above the base of the heart. This 
dulness is of great diagnostic import. It is due to the dilated great 
vessels at the base of the heart. 

As an exception to the above classification may be mentioned the 
case of Sansom, in which cyanosis and extreme ana?mia were present. 
In rare cases, the second pulmonary sound may be very low. The 
murmur may be conducted into the axilla, the right heart not being 
dilated. 



DISEASES OE THE HEART. 689 

Open Ductus Arteriosus or Ductus Botalli [Ductus Disease). — ■ 
This is a very rare congenital defect. There are in the literature 
only 20 cases of uncomplicated open ductus arteriosus in which 
autopsy confirmed the clinical diagnosis. Of these, only 5 occurred 
in infants under one year of age, and 5 others ranged from the first 
to the tenth year (Vierordt). The complicated cases occur with 
stenosis of the pulmonary artery, septum defects of small extent, and 
open foramen ovale. 

Physical Signs. — Cyanosis. — Cyanosis is not present in the major- 
ity of cases, or if present is so only at intervals and is not marked. 

Murmur. — The murmur is a loud buzzing systolic murmur heard 
with greatest intensity over the pulmonary artery, and not conducted 
downward, hut conducted to the left of the sternum into the veins of 
the neck (Hochsinger). 

There is an accentuated second pulmonic sound which can be 
heard in the carotids. 

Right Ventricle. — The presence of hypertrophy of the right ven- 
tricle tends to confirm the diagnosis ; if the left ventricle is also hyper- 
trophied, greater certainty is added. This is of great moment, since 
hypertrophy of the left ventricle is not present in any of the other 
congenital defects, except those connected with the anomalies of the 
aorta and aortic system and which have only a scientific value, since 
the literature contains no cases which have been diagnosed during 
life. The dulness in the second space referred to under Pulmonic 
Stenosis is also of value. 

Congenital Defects of the Auricular Ventricular Septum ; Defects 
of Auricular Septum; Open Foramen Ovale. — Inasmuch as 44 per 
cent, of the autopsies upon individuals who during life showed abso- 
lutely no signs of cardiac disturbances reveal a patency of the foramen 
ovale, the diagnosis of the condition as an uncomplicated entity should 
be made with great reserve. This congenital defect is generally 
found to exist in connection with other defects of a congenital nature 
(stenosis of the pulmonary artery). 

Cyanosis has been found in all the cases in which autopsy has 
been made. In a case recorded by Foster, there was cyanosis with 
a varying systolic and presystolic murmur at the sternal end of the 
third or fourth costal cartilage. 

Walshe denies that a patency of the foramen ovale may of itself 
cause a murmur. 

Congenital Deficiency of the Ventricular Septum; Maladie de 
Roger. — Autopsies have shown that this condition may exist during 
life without giving any signs of its presence. Moreover, it is so often 
combined with other congenital hearl anomalies, such as stenosis of 
the pulmonary artery or ostium, or ductus Botalli that the signs oi 

44 



690 DISEASES OF THE CIECULATOEY SYSTEM. 

the ventricular condition must of necessity be obscured by those of the 
complicating defect. 

Cyanosis. — Cyanosis has been present in some cases of uncompli- 
cated defect of the ventricular septum (Miiller) and absent in others. 
It is present in the cases complicated with pulmonary stenosis. 

Murmur. — According to Roger, a loud systolic murmur is heard 
over the whole prsecordium, toward the median line, over the upper 
third of the cardiac area. According to others (Miiller), the murmur 
has no special point of greatest intensity. It is not conducted into 
the vessels of the neck. I have seen such a case in a child 13 months 
of age. 

Rauchfuss calls attention to the fact that with this murmur the 
distinct valvular character of the heart-sounds at the various valves 
should be heard. The case of Miiller was that of a cyanotic infant 
two months old. A loud murmur having no special point of greatest 
intensity was heard over the whole cardiac area. The valvular 
sounds were distinctly heard. Autopsy showed uncomplicated defect 
of the ventricular septum. 

Acute Endocarditis. — Acute endocarditis is an inflammation of 
the lining membrane of the heart. That covering the valves and 
their immediate vicinity is the area generally affected. There is also 
an inflammation, slight or marked, of the muscle tissue of the heart, 
and in some cases there is inflammation of the pericardium. Endo- 
carditis thus involves structures of the heart other fhan the endo- 
cardium. Acute endocarditis may be benign, septic or as formally 
called malignant. Between the two extremes, there are all gradations 
as to severity. All forms of endocarditis are caused by infection 
which in the malignant variety is of the severest septic type. Foetal 
endocarditis affects the right side of the heart; after birth, the left 
heart is chiefly affected. The condition is less frequent before than 
after the fifth year of life, and occurs with equal frequency among 
boys and girls (Steffen). 

Etiology. — Acute endocarditis occurs most frequently with acute 
articular rheumatism, but may appear in any infectious disease. It 
is often found in scarlet fever; less often in measles. I have seen 
it in rare cases of erythema nodosum (2 cases). It may occur with 
typhoid fever, diphtheria, influenza, pneumonia (better), cerebro- 
spinal meningitis, and tuberculosis. In fact, all forms of sepsis, such 
as osteomyelitis, either foetal or in the newborn infant or in children, 
may be accompanied by endocarditis. Endocarditis is present in 16 
per cent, of the cases of chorea and is always present in fatal cases 
of that disease. 

Bacteriology. — The most important bacteria bearing an etiological 
relationship to endocarditis are the streptococci of the various varie- 



DISEASES OF THE HE ART. 691 

ties and the Staphylococcus pyogenes. ITarbitz divides endocarditis 
into the infectious and the non-infectious varieties. He found bac- 
teria in the vegetations in most of the infectious cases, streptococci in 
39.5 per cent, and staphylococci in 18.6 per cent, of the cases; other 
bacteria, such as the pneumococci, were also found. The cases in 
which no bacteria were found were healed cases. He thinks that the 
staphylococci most often cause pysemic endocarditis with ulcerations 
and metastatic abscess. Welch and Lenhartz found streptococci in 
ulcerative endocarditis. The Diplococcus pneumoniae is next in im- 
portance as an etiological factor. Wright found the Bacillus diph- 
theria in one case. Other bacteria, such as the Gonococcus, the 
Bacillus endocarditidis griseus (Weichselbaum), the Micrococcus 
endocarditidis rugatus and capsulatus, the Diplococcus tenuis (Klem- 
perer), have been found in cases of adult endocarditis. Although 
they are all, as well as the Bacillus typhosus, doubtless capable of 
causing the same process in children, actual clinical cases are still to 
be published. 

All forms of endocarditis are thus septic processes due to the 
circulation in the blood of bacteria or their toxins. In some cases 
it is possible to discover the point of entrance of the bacteria into 
the circulation, in others it cannot be fixed upon. The various forms 
of endocarditis are not so uncommon in infants as is supposed. The 
tonsil is a great avenue for the entrance of bacteria or toxins into 
the circulation (Cheadle). It is believed that many cases of endo- 
carditis in children originate in this manner (Packard). I have 
frequently met with endocarditis in which the only other clinical 
manifestation was a slight redness or swelling of the tonsils. The 
integrity of the endothelium of the endocardium must be compro- 
mised if bacteria have invaded the tissue of the valvular endocardium 
(Prudden). It is supposed that the toxins produced by the bacteria 
circulating in the blood reduce the resistance of the endothelial lining 
of the endocardium, thus preparing the soil for bacterial invasion. 

Morbid Anatomy. — In some cases the only lesion is a swelling of 
the valves. They are thickened and succulent, their surface being 
smooth. The basement substance is swollen and there is an increase 
of connective-tissue cells (Delafield). In other cases the borders of 
the valves present transparent, gelatinous, whitish-yellow or reddish 
formations, varying from the size of a pin's head to that of a bean. 
These are irregular in shape, cover both surfaces of the valves, and 
may be single or multiple. They are also seen on the chordae tendinese. 
The free border of the valve is warty or papillomatous (endocarditis 
verrucosa or polyposa) (Xiogler). The papillae may appear on the 
free surface of tin 1 valves. There may be a loss o\' substance with the 
formation o( adherent thrombi o( a whitish or reddish color and of 



692 



DISEASES OF THE CIRCULATOBY SYSTEM. 



tenacious consistency (endocarditis ulcerosa). Small foci of pus 
may be present in the heart substance (endocarditis pustulosa). 

Bacterial invasion of the surface of the valves results in loss of 
substance, formation of thrombi, and changes in the nuclei of the con- 
nective tissue (necrobiosis). The mitral valve being more vascular 
is sooner affected than the aortic or pulmonary valves. Exudation on 
the valve is replaced by new connective tissue ; excrescences and new 
formations become permanent. If the bacteria penetrate deeply, 
thickening of the valve results. Large thrombi are organized, and 
the valves become shrunken and distorted. Ulceration and loss of 
substance may result in perforation of the valves. The thrombi just 
mentioned are sometimes made up of blood-plates ; in other cases leuco- 
cytes, blood-cells, and fibrin in varying amounts are present. 

There may be exudative pericarditis. The myocardium is the 
seat of degeneration, which leads to dilatation, abscess or aneurism 
of the heart muscle. Through the separation of portions of the 
thrombi or of the vegetations on the valves, these particles may be 
carried into the circulation. Containing, as they do, bacteria (my- 
cotic emboli), they cause secondary infections with necrosis or abscess 
in the kidney, spleen, and brain. 

Fig. 155. 



HOUR 3 9 12 3 9 12 3 > 9 12 3 9 12 3 9 12 

102° 1 i ' 1 

Hli plpipp 


3,0)9 12 3 9(12 3 9 12 3 6 9 12 3 9 12 

4rm 




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RESP. -f, ^i pjl -^ .^i Sp ?|-* -* ,-j< -* -*■ ^3 -*• n y> m 


roco^OCOrOrOTO^rOCO^rO fjrococi -Mid 



Endocarditis complicating influenza. Second week of the illness. Mitral systolic 
murmur developed under observation. Female child, four years of age. 



Symptoms. — The symptoms of acute endocarditis are those of some 
general infection. They are not in infants and children so charac- 
teristic as to direct attention to the heart. Infants cannot and chil- 
dren do not complain of pain, palpitation, or uneasiness in the pre- 
cordial region as adults sometimes do, and therefore unless the heart 
is carefully examined as a routine procedure, the simple cases of 
endocarditis will escape observation. The most interesting cases are 
those which begin with all the symptoms of an attack of influenza 
or tonsillitis. There are fever, rapid pulse, and an increase of the 
respirations to 36 or 40. The fever, however, does not subside in 



DISEASES OF THE II E ART. 



693 



the time occupied by the course of one of the above affections; it 
continues high, 103°-104 o -105° F. (39.4°-40.5° 0.), with morning 

or afternoon remissions. 

In such cases a most careful examination of the lungs and other 
organs fails to reveal anything abnormal. The heart, however, shows 
the presence of endocardial inflammation. In some obscure cases, 
there is an increasing pallor with a slight daily rise of half a degree 
or a degree in body temperature, which will continue for days or even 
weeks and give rise to a suspicion of paludal poisoning. There is 
also an increasing pallor. Examination of the heart reveals the 
lesion. In other cases there are a very slight but increasing pallor, 
weakness, and indefinite pains in the bones and joints. In children, 
more than in the adult subject, we are apt to have monarticular affec- 
tions of a rheumatic nature. 

Fig. 156. 




Chronic cardiac disease, hypertrophy, and dilatation of the left and right ventricles. 
Enlarged liver and spleen, ascites, cyanosis, recurrent attacks of endocarditis. Tempera- 
ture by rectum shows a subnormal range. Boy, twelve years of age. 



I have seen several cases of monarticular joint-affection with an 
endocardial murmur in childhood. One case was that of a child two 
years and eight months of age, another was that of a child eight years 
of age. In the one case the ankle was swollen, painful, and slightly 
reddened. There was no temperature. There had been slight pain 
in one knee some days previous to the ankle-affection. In the other 
case the metatarsal phalangeal joint of the small toe was involved. 

In young children the joints may be painful, and still no history 
of joint-pain will be given, and the first indication of pain is a decided 
limp in walking. These obscure joint-pains are the first symptom of 
endocarditis. The rheumatic cases are as a rule easily diagnosed. 
The heart should be regularly examined in such cases. The endo- 
carditis which complicates chorea sometimes runs its entire course 
without any rise in the body temperature. 1 have, however. In en 
able in such cases to confirm the statement o\ Jiirgensen, that the 
normal diurnal temperature variations are distorted that is to - 
the morning temperature may he higher than the evening tempera- 



694 DISEASES OF THE CIRCULATORY SYSTEM. 

ture. In other cases of chorea there is a distinct rise of tempera- 
ture without any increase of the respirations and pulse-rate during 
the active stage of the endocarditis. After the symptoms of chorea 
have begun to decline there is occasionally a rise of temperature last- 
ing a day or more, which may indicate a slight recurrence of the 
endocarditis. In other cases I have observed a subnormal tempera- 
ture of a degree or more lasting for days. This occurred in a case 
of recurrent endocarditis. Thus the temperature is not at all charac- 
teristic. The heart in children is extremely irregular. It may vary 
from 60 to 120 per minute within a few days, and may vary at differ- 
ent times of the same day. Under such conditions it may be sur- 
mised that there is a myocarditis. The respirations are increased. 
The children do not complain of the heart. 

In pneumonia, scarlet fever, and measles, the endocarditis is 
masked by the symptoms of the primary disease. 

Physical Signs. — A murmur which develops while a child is under 
observation is indicative of acute endocarditis. 

Inspection.- — Inspection may reveal nothing abnormal, or there 
may be extreme irregularity of the action of the heart. There may 
be increased action, as evinced by visible pulsation over the cardiac 
area. 

Palpation.- — Palpation also may reveal nothing abnormal; there 
may be a thrill over the apex. 

Percussion. — Percussion at first reveals nothing abnormal. In 
some cases there is a slight dilatation of the left ventricle (Steffen) 
as the disease progresses. I have seen this dilatation in cases in 
which the condition had existed for a week. During convalescence 
the dilatation may retrograde and the heart confines return to their 
normal limits. 

Auscultation. — In the majority of cases, a soft systolic murmur 
is heard over the apex and the mitral area. There is rarely a pre- 
systolic murmur. There may be murmurs at the other valves, having 
the characteristics of the same murmurs in the adult. 

In any acute disease, the physician should be careful to observe 
a murmur very carefully before pronouncing it organic. I have 
found murmurs, especially in typhoid and scarlet fever in young and 
older children, which appeared and disappeared. Such murmurs are 
hsemic or myocarditic and functional ; they are very gentle, generally 
systolic, and are limited very closely to the apex or pulmonic area. 
They are not conducted and there are no positive signs of dilatation. 
Jacobi has described pulmonic murmurs in very young infants, which 
were at autopsy shown to be functional. On the other hand, if a 
murmur is distributed over a valvular area, takes the place of the 
valvular sound, is conducted into the arteries, and occurs in connec- 



DISEASES OF THE HEART. 



G95 



tion with signs of dilatation, the physician is justified, acute symptoms 
being in evidence, in assuming the presence of organic disease. 

Course and Prognosis. — Many cases of endocarditis, especially 
those not of rheumatic origin, run their course, do not recur, and in 
after-life give no symptoms referable to the heart. Others run an 
acute course without developing any physical signs until convales- 
cence. I have seen such forms follow chorea. The murmur develops 
in the intervals of freedom from symptoms of chorea. Rheumatic 
cases are likely to recur, and in this tendency lies the danger. The 
prognosis as to immediate recovery is very good in all of the ordi- 
narily severe cases of acute endocarditis. The severer septic or 
malignant cases give a grave prognosis. The future of cases of acute 



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Recurrent endocarditis with acute articular rheumatism which developed under obser- 
vation. Boy, twelve years of age. 



endocarditis which have recovered will depend very much on the 
immediate management. I have seen patients who had been allowed 
to be up and about too early and to participate in sports, develop after 
a few months symptoms resembling those seen in acute dilatation due 
to heart strain. These cases show a marked dyspnoea on exertion and 
cyanosis after play. The children are easily fatigued. They have 
pain and uneasiness over the region of the heart after running. On 
percussion an abnormally large heart area is found. 

Treatment.- — The treatment of acute endocarditis is directed toward 
limiting the damage done by the disease to the heart. Rest in bed is 
necessary. The patient should not be allowed to maintain the sitting 
posture, but should be recumbent. The rest should be continued 
long ofter the subsidence of the active symptoms. The symptoms 
and physical signs are the guides as to its duration. If there have 
been marked disturbance of the heart action and distinct dilatation 
of the ventricle with signs of myocarditis such as great irregularity 
of the pulse, the stay in bed should be prolonged for weeks. 

If the action oi' the heart is rapid and tumultuous, an ice-bag 
should be placed ever the cardiac area. This remedy is also useful 
in cases in which the heart action is not very rapid, but in which there 
arc nevertheless signs o( active inflammatory disturbances. 



696 



DISEASES OF TEE CIECULATOEY SYSTEM. 



Salicylate of sodium is a favorite remedy, not only in eases with 
a rheumatic history, but also in septic cases. The dosage is one grain 
combined with double the amount of bicarbonate of soda for every 
year of the age. Some children have stomach disturbances after 
taking salicylates. There must then in the rheumatic cases be sub- 
stituted some alkali, such as bicarbonate of soda. Aspirin is given 
in many cases with apparent benefit. A few drops of the tincture 
of digitalis will be useful in regulating the heart action late in the 
disease. Digitalis is given for periods of a few days and then sus- 
pended for a time, after which it may again be given if necessary. 
Care should be taken to support but not to drive the heart. The diet 
should be light, fluid, and easily assimilable. The bowels are best 
regulated with some saline cathartic or rectal enemata. 

Fig. 158. 




Fatal septic endocarditis following a pneumonia. Streptococci found by culture in the 
blood during life. Girl, eight years of age. 



The temperature, if high, may be treated in the same way as in 
other acute diseases. Baths of low temperature should not be given. 
The temperature in this disease is of so short duration that in the 
majority of cases sponging with cold water is effective. The man- 
agement of choreic cases will be discussed in the section on Chorea. 

Septic, Ulcerative, or Malignant Endocarditis. — This form of 
endocarditis is rare in infants and children. Adams collected 47 
cases in children. The sexes were about equally affected. Three 
cases were congenital and 8 were five years of age or under. The 
others ranged up to fourteen years. The trend of opinion (Adams) 
supports the contention of Lazarus, Barlow, and Weichselbaum, that 
these cases differ from the benign cases only in degree of severity. 
Dreschfeld divides these cases into the following classes: (a) the 
primary form, (b) the form complicating septic disease, (c) the form 
complicating pneumonia and meningitis, (d) the form which occurs 



DISEASES OF TEE HEART. 



Ml 




698 DISEASES OF THE CIRCULATORY SYSTEM. 

as a mixed infection due to septic organisms in the acute infectious 
fevers or which is secondary to the rheumatic affections of the valves. 

Symptoms. — In one of my cases occurring in a boy with osteomye- 
litis of the tibia, staphylococci were found in the blood during life. 
In another case, which followed a pneumonia, streptococci were found 
in the blood during life. In the former case hemorrhagic symptoms 
and signs of severe cardiac disease, such as gallop-rhythm were 
observed. 

The latter case was seen in my hospital service. The child, a 
girl of eight years, had had a pneumonia three weeks previous to her 
admission. She had apparently recovered, had sat up in bed after 
ten days, and was about. A day before her admission the tempera- 
ture mounted to 104° F. (40° C), she vomited, and had diarrhoea. 
The child showed much prostration, and on examination an area of 
consolidation was found in the right lung behind. She had an active 
endocarditis giving a mitral systolic murmur. The liver and spleen 
were large; the temperature rose and fell twice daily, chills and 
dyspnoeic attacks preceding each rise. The temperature subsided to 
the normal or subnormal after each rise. There were nausea, vomit- 
ing, and signs of cardiac failure. The heart did not at first show 
any enlarged area of dulness. After a few days the left ventricle 
showed an increased area of dulness to the extent of 2 to 3 centimetres 
outside the nipple-line (acute dilatation), with diffusion of the apex- 
beat. The right ventricle was dilated. With the extreme fluctua- 
tions of temperature, the child became delirious. The heart, as at 
the time of admission, showed a mitral systolic murmur. After ten 
days petechias appeared, first on the neck and upper thoracic region, 
and increased both in number and extent. The face and eyes became 
eedematous (cardiac failure). The patient became unconscious and 
died in coma with Cheyne-Stokes respiratory phenomena. The 
blood withdrawn during life showed in culture the presence of long 
streptococci. 

I have seen several cases of septic endocarditis in which the symp- 
toms were exceedingly mild in contrast with those described above. 
The patients showed few subjective symptoms, there was an increas- 
ing anaemia, and they even wished to be up and about. While there 
was some lassitude, the patients sat up in bed, played with their toys, 
and were in excellent humor. The rises in temperature were irreg- 
ular, rarely exceeding 103°. A few petechias, were discoverable on 
the orbital conjunctiva?. There were the physical signs of endocar- 
ditis, such as murmurs and dilatation of the ventricle. These cases 
showed an attenuated form of Streptococcus in the blood by repeated 
culture. Such cases may recover or go on to more active symptoms 
and death (Fig. 159). 



DISEASES OF IRE RE ART. 699 

Diagnosis. — The diagnosis of septic endocarditis rests on the his- 
tory and the presence of cardiac signs, the prostration, the fluctua- 
tions in temperature in severe cases resembling those in sinus throm- 
bosis in ear disease, the onset of chills and delirium, the presence 
of petechia^ and lastly on the results of examination of the blood 
for bacteria. 

Of great interest in this connection, are the cases of chronic recur- 
rent endocarditis which toward the close of the disease have certain 
symptoms resembling those of the septic or so-called malignant canes. 
In a child of ten years suffering from chronic recurrent rheumatic 
endocarditis, there was toward the close of the illness a period during 
which phlebitis with thrombosis of the deep veins of the neck and 
arms on both sides and oedema of the corresponding extremities devel- 
oped successively. After a few weeks the symptoms of phlebitis and 
thrombosis gradually subsided and there was a period of a few weeks 
during which the patient was much improved. The fever and ana- 
sarca subsided and the heart action was good. Before the fatal issue 
the endocarditis recurred and there were fever and what appeared to 
be significant petechias on various portions of the body. The case 
was a rheumatic one and had been under observation for two years. 
Its outcome gives weight to the theory that a seemingly benign endo- 
carditis may at any time take on a malignant or septic nature. 

Prognosis. — All the severer forms of septic endocarditis give a 
grave prognosis. The milder forms may make an apparent tem- 
porary recovery. Thomson has recently reported such cases in adults. 
In children such an outcome is not impossible though the outlook even 
in the mildest forms of septic endocarditis is always linked with 
uncertainty. 

Treatment. — The treatment of septic endocarditis does not differ 
from that of acute endocarditis. There is, however, the question as 
to the annihilation of the bacteria in the blood as a preliminary to 
permanent cure. This is still one of the problems of internal medi- 
cine. We have no sera or vaccine which is effective. I have tried 
both with discouraging results. 

Chronic Valvular Disease of the Heart. — The lesions in chronic 
valvular disease in infancy and childhood are the same as in the adult 
subject. 

Etiology. — The etiology has been considered in the section on 
Endocarditis. 

Frequency. — Of 70 of my cases of chronic valvular disease. 37 
were of the female and 33 of the male sex; 2 were below the age ot 
two years; 24 from the second to the fifth year, and 39 from the fifth 
to the tenth year of life. Ill 50 of the 70 cases the mitral valve was 
involved, causing either a systolic or a diastolic murmur, or both. 



700 DISEASES OF THE CIRCULATORY SYSTEM. 

The following table will give an idea of the relative frequency of the 
valvular lesions : 

Mitral insufficiency 26 cases. 

Mitral stenosis _ 6 ' 

Mitral insufficiency and stenosis 18 

Aortic stenosis 6 ' 

Aortic stenosis and insufficiency 1 case. 

Endocardial and pericardial disease 5 cases. 

Combined lesions of mitral and aortic valves 8 

Physical Signs. — The physical signs, the reservations noted in the 
section on cardiac murmurs being made, are the same as in the adult 
subject. On the other hand, certain characteristics of the disease in 
childhood are not common to the adult subject. There are cases of 
chronic cardiac disease in infancy and childhood which escape recog- 
nition because the heart is not examined with sufficient care. Mur- 
murs of mild intensity pass unrecognized. 

There are cases of endocarditis which run an obscure course, give 
very few symptoms, and which are apt to recur at the onset of tonsil- 
litis or an attack of influenza. These cases of chronic endocardial 

disease give very few symptoms 
in the intervals between the at- 
tacks. There may be obscure 
pains in the limbs or joints 
which are not interpreted by the 
physician as purely rheumatic, 
but are believed to be of a grip- 
pal character. The patients may 
eventually develop symptoms of 

Simple mitral insufficiency; dilatation of serious cardiac insufficiencv. 
the left ventricle. Girl, six years of age. 

The cases of chronic valvular 
disease resulting from an attack of some infectious disease may leave 
the heart little compromised. It is true that upon examination there 
is a cardiac murmur, but the cases reveal no subjective symptoms. 

They have what is called a healed endocarditis. They may, how- 
ever, develop serious cardiac symptoms at the onset of an infection 
of the intestine or other organs. The heart in these cases may be 
called irritable. The patients do not develop inflammation of the 
endocardium or pericardium as do the rheumatic cases. On slight 
disturbance of the intestines, such a heart, even when there is no 
fever, acts very much like a hypertrophied organ. There is an in- 
crease not only of the frequency, but also of the force of the heart's 
impulse. The vessels are also affected, and there is a bounding full 
pulse at the radial. As a result of the infection and of the congestion 
brought about by the increased action of the heart, there will be 
albumin and casts in the urine. These symptoms subside and do not 




DISEASES OE THE HEART. 



01 



recur except at long intervals. In the intervals, with the exception 
of a valvular murmur, there are absolutely no signs of cardiac disease. 
In children, cases with a slight or marked valvular lesion which 
is apparently at a standstill, give certain symptoms which are sig- 
nificant of defective cardiac action. On exertion, the children com- 
plain of pain in the side or the epigastrium. Examination will show 

Fir;. 161. 




Chronic cardiac disease ; dilatation of the right and left ventricles. Epigastric pulsa- 
tion. Boy, six years of age. 



little change in the cardiac, area. The valvular murmur is heard. 
Such hearts are also irritable. I have often found a distinct history 
of palpitation occurring at intervals and even in the absence of exer- 
tion. Many children with chronic' cardiac disease of a very mild 
and absolutely quiescenl type, exhibit a persistent pallor which does 
not yield to drugs. Children without other symptoms complain o( 
headaches after slight excitement. Examination will, in those cases 
also, show a sliffhl hitherto unrecognized chronic cardiac valvulitis. 



702 



DISEASES OF THE CIBCULATOBY SYSTEM. 



Slight oedema of the eves which is persistent should direct attention 
to the heart. 

Many cases without any other signs of chronic cardiac disease 
show a slight evanescent trace of albumin in the urine. 

There may be absolutely no signs of cardiac insufficiency or change 
in the physical character of the organ. Children with signs of quies- 

FiG. 162. 




Chronic cardiac disease ; great cardiac dilatation : recurrent attacks of endocar- 
ditis ; phlebitis and thrombosis of the deep veins of the neck and arm on both sides 
successively ; oedema of the corresponding arm and forearm ; great dilatation of the 
superficial cervical and thoracic veins. Female, ten years of age. 



cent cardiac disease often have obscure attacks of faintness and vom- 
iting, following every little excitement. 

The rheumatic recurrent cases of endocarditis in childhood ex- 
hibit very much the same symptoms of cardiac insufficiency as the 
corresponding cases in adults, viz.. enlargement of the liver and 
spleen. Children appear to recuperate more rapidly than adults, but, 



DISEASES OF TEE HEART. 703 

on the other hand, the attacks are more likely to recur in them thai] 
in older subjects. A compromised heart in a child will bear more 
strain than in an adult. Cases are frequently seen in which children 
show on physical examination marked chronic disease, but are not- 
withstanding exceedingly active and show no symptoms referable to 
the heart. The signs of insufficiency of the cardiac muscle are the 
same in children as in the adult. There is dyspnoea on exertion, 
slight oedema of the general surface, and enlargement of the liver and 
spleen. In the later stages, there are transudates in the pleura and 
abdomen. In some cases, especially where there is progressive inter- 
stitial myocarditis with adherent pericardium, the pleura may show 
unilateral transudate. 

In cases of cardiac insufficiency, the pulse is persistently high or 
very irregular. There is persistent dyspnoea. Children with car- 
diac disease suffer, as a rule, less than adult subjects. 

Cardiac angina is not an uncommon symptom in cases of aortic 
disease. It is present in cases in which there are signs of lack of 
compensation. . The angina comes on in attacks occurring chiefly at- 
night, and is very severe. I have seen a boy of eight years with an 
aortic murmur suffer from these attacks for days. In such cases there 
are a dilated ventricle and an enlargement of the liver and spleen. 

Prognosis. — The prognosis of chronic valvular disease in childhood 
depends very much on the type of disease. If the heart is only 
slightly affected and the patient not a rheumatic subject, the outlook 
is good. With careful management all ill after-effects can be avoided ; 
children thus affected may grow to adult life without suffering from 
any symptoms referable to the heart. If, on the other hand, they are 
attacked by any intercurrent disease, such as scarlet fever, the heart 
may again become the seat of inflammatory processes. The patients 
may, however, recover and continue free from symptoms for years. 
The rheumatic cases give the most unfavorable prognosis. These 
are prone to recurrent attacks of endocarditis, each attack leaving the 
heart in a more weakened condition than before. Most of my cases 
have been children who, having had one attack of rheumatic endo- 
carditis, suffered from the affection to a greater or lesser degree for 
years. Within a few years of the first attack they succumb to pro- 
gressive non-compensatory cardiac disease. 

Treatment. — Many cases of cardiac disease in infancy and child- 
hood give no symptoms and need very little treatment beyond careful 
and judicious management. Children thus affected should have a 
carefully regulated dietary, and should no1 indulge in sports which 
subject the heart to strain. They should not ride the bicycle, but 
may, however, indulge in many o( the amusements of children, such 
as skating, roller skating, swimming to a moderate degree, and horse- 



704 DISEASES OF THE CIRCULATORY SYSTEM. 

back exercise. They should be under constant observation, and when 
attacked by any acute infection, however slight, should be put to bed, 
and kept quiet until long after convalescence. In these cases an anti- 
rheumatic course is pursued even although the illness be only a mild 
attack of influenza or tonsillitis. It is well to give the salicylates in 
small doses for several days and to keep the bowels open with some 
alkaline cathartic. With children who suffer from rheumatism, the 
nature of the primary disease should not be forgotten. They should 
have constant antirheumatic treatment even when the cardiac disease 
is at a standstill. 

Any rise of temperature should be regarded as a threatening sign 
and the patients put to bed for perfect rest until the crisis has passed. 
In cases in which there is marked dilatation or pericardial involve- 
ment, any exacerbation of symptoms is a signal for immediate rest 
in bed. Slight oedema of the surface and swelling of the liver and 
spleen will subside if treated with perfect rest, a light assimilable 
diet (milk), and mild alkaline catharsis. It is not always necessary 
to use digitalis. If given at all, it is best administered in the form 
of the infusion or a reliable tincture. I am accustomed to use this 
drug for a period of two or three days, after which I discontinue it. 

In some cases of uncontrollable vomiting the digitalis may effect- 
ually be given in form of infusion by the rectum. There is no doubt 
that its action continues after the administration is stopped. Con- 
vallaria in the form of the fluid extract is at times one of the most 
useful remedies in cases in which digitalis has failed to give relief. 
If there is great dyspnoea or orthopnoea, codeia in moderate doses 
should be used. 

Young children do not bear morphine well. It certainly should 
not be used hypodermatieally. Nitroglycerin in doses of grain Moo 
(0.0006) relieves the angina. In aortic disease, I administer mor- 
phine only to older children, and then only when the nocturnal 
attacks of angina are very severe. In young children with irritable 
heart, codeia is an exceedingly useful remedy. I have not found 
strychnine very useful in the chronic forms of cardiac disease. Caf- 
feine in moderate dosage seems more useful in correcting the irreg- 
ularity of the pulse or bradycardia seen in some of these cases. In 
combination with digitalis it gives excellent results. If ascites 
appears, the patient should be promptly tapped to relieve the circula- 
tion and the abdomen supported by a binder. If there is a pleuritic 
effusion at the same time, it should not be disturbed. With relief of 
the abdominal distention, the pleuritic effusion often disappears. 

Cardiac Murmurs. — Cardiac murmurs which are the result of 
disease or insufficiency of the valves of the heart have the same gen- 
eral character as those in adults, the following being the chief points 
of difference: 



DISEASES OF TEE HEABT. 705 

a. Cardiac disease of a very serious character may exist (as in 
congenital cyanosis) without any murmur. 

b. Cardiac murmurs are as a rule louder in children than in 
adults. The loudness is therefore no guide as to the seriousness of 
the affection. 

c. Cardiac murmurs in children are sometimes heard conducted 
over the whole chest; diagnosis of disease of a particular valve must 
be based on the greatest intensity of the murmur at that point. 

d. Haemic and dynamic murmurs in children under four years 
of age are not so common as is supposed. There should be no hesita- 
tion in making the diagnosis of organic affections in systolic, basic, 
or apex murmurs if there are distinct conduction or signs of dilata- 
tion or hypertrophy. This is especially to be remembered in chorea, 
extreme anaemia, and in febrile affections where rapidity in time and 
rhythm (gallop-rhythms) causes adventitious sounds. 

e. The conduction of the aortic murmurs into the arteria fern or- 
alis occurs in occasional cases in children. Pulsation of the liver or 
spleen, as found in aortic disease of adults, is rare in children 
(Steffen). 

The peculiarities of the aortic pulse and so-called pistol-shot 
sound in the femorals are observed in children as in adults. 

Accidental Cardiac Murmurs. — Accidental murmurs are divided 
into those heard over the heart, in the arteries, and in the veins. The 
study of the accidental murmur of the heart in infancy and childhood 
has been much neglected. West and Hochsinger give the most val- 
uable data. The principal points of difference between the murmurs 
in infants and children and those in the adult are as follows : 

Cardiac Murmurs. — Anosmia. — The severest forms of ana?mia in 
my experience sometimes fail to give haemic murmurs. Xot one of 
200 cases under four years of age examined by Hochsinger gave 
anaemic murmurs. After the fourth year and up to the seventh year 
of life the frequency of the anaemic and haemic murmurs increases. 
I have in cases of pernicious anaemia found a mild blowing basic 
murmur. One such case occurred in a child under four years. 

Fevers. — The hsemic murmurs so common in the febrile affect ions 
of adult life are rarely heard even in severe febrile affections with 
anaemia, in patients under the age of three years. I have heard 
hsemic murmurs in children under three years of age, with severe 
typhoid fever. They are common in typhoid fever in older children. 

Characteristics of Ancemic Murmurs. — These never occur with 
signs of cardiac dilatation or hypertrophy. They arc not conducted 
into the arteries. They never entirely take the place o\' the valvular 
cardiac sounds, but accompany them. They are sofl blowing mur- 
murs, heard at times most loudly at the pulmonary valve, sometimes 

45 



706 DISEASES OF THE CIECULATOBT SYSTEM. 

heard over the base and whole prsecordium, and faintly heard at the 
apex. They are never heard at the aortic or tricuspid valves, or 
behind. They are inconstant, disappearing for a time and again 
appearing at the various points in the chest. 

Accidental Arterial Murmurs. — The theory held by some observers, 
that pressure of the stethoscope on the arteries of the neck may cause 
a murmur, should be entertained with caution. Correct stethoscopy 
will hardly lead to such an error. A murmur in the large arteries 
of the neck is conducted from the heart and is invariably organic 
in origin. I have heard aortic murmurs conducted in the femoral 
artery. 

Venous Hum. — Although cardiac accidental murmurs due to 
anaemia are rarely heard in children, the venous hum due to the same 
cause is frequently heard. In young infants and children it is pres- 
ent in the veins of the neck, is quite loud, and is heard at either side 
of the upper part of the sternum. If there is anaemia due to valvular 
cardiac disease, the venous hum is heard in the arteries of the neck, 
with the organic murmur. 

Myocarditis. — Myocarditis is very frequent in infancy and child- 
hood. Most of the knowledge of this condition has been obtained 
from a study of the disease in young subjects. This is due to the 
fact that in early life the heart is especially exposed to the deleterious 
action of the toxins of the infectious diseases. Myocarditis is a 
degeneration or inflammation of the muscular substance of the heart, 
secondary to the action of poisons (phosphorus) to the toxins of bac- 
teria (as in the exanthemata, typhoid fever, diphtheria, pertussis, 
sepsis, osteomyelitis), or to the changes consequent upon disease of 
the pericardium, or endocardium, of rheumatic or infectious origin. 

Etiology. — The degenerative or inflammatory changes may be 
caused by the direct action of the bacteria (Almquist), but usually 
the influence of the bacteria themselves is only slight, since they do 
not find in the myocardium a favorable soil for growth. The toxins 
of these bacteria produced either elsewhere in the economy and 
circulating in the blood, or in the heart muscle itself, are chiefly 
instrumental in causing the degenerative changes (Welch, Flexner, 
Schamshin). Fever, as such, has only a slight influence in causing 
myocarditis (Werhofsky). 

Morbid Anatomy. — If there is degeneration of the myocardium, 
the muscular fibre may be the seat of fatty changes. There is an 
increase of fat drops in the muscular tissue of the heart. In advanced 
conditions, the fatty changes are apparent to the naked eye as a yel- 
lowish discoloration beneath the endocardium. In other cases, there 
is a granular or hyaline degeneration of the muscle fibre or a vacuole 
formation. The cell protoplasm becomes cloudy, hyaline, loses its 



DISEASES OF THE HEABT. 707 

striation, and disintegrates or is replaced by drops of fluid. This 
occurs in diphtheria, typhoid fever, pneumonia, chronic congestion, 
and in toxemia of various kinds. Thrombi may form in hearts 
which are the seat of advanced degeneration. In toxaemia and the 
infectious diseases, there is inflammation of the myocardium. There 
is an invasion of the muscle tissue by bacteria from the endocardium 
(staphylococci, streptococci, and pneumococci). In such cases, there 
are also grayish or yellowish discoloration of the muscle tissue, vacuo- 
lization, and granular and hyaline degeneration. The muscle tissue 
is the seat of small cell infiltration or there may be abscesses of micro- 
scopic or macroscopic size. If recovery occurs these areas may cica- 
trize with formation of connective tissue. Tuberculous and syphilitic 
inflammations of the myocardium occur, but are rare. 

Symptoms. — The symptoms of myocarditis can best be understood 
by studying the heart in the various infectious diseases. In diph- 
theria, myocarditis may be suspected if there occur sudden syncope, 
faintness, chilly sensations, vertigo, and vomiting. The patients 
complain of precordial weakness ; there are all the symptoms of col- 
lapse and a flickering, irregular pulse. These phenomena may appear 
at intervals throughout the disease and persist far into convalescence. 
In this disease there is during convalescence an irregularity of the 
heart apparent in the rhythm and force. There will be two or three 
beats and then an interval, followed by two or three beats. The 
pulse at the wrist may be of varying compressibility. In these cases 
there may be no other manifestation of the effect of the poison of the 
disease on the heart-muscle and ganglia. There is no pain, no vom- 
iting, no precordial distress, yet for days the heart-action will remain 
irregular and cause great uneasiness to the physician. Such cases 
may make a good recovery. 

In some exceptional cases, however, these symptoms precede more 
serious disturbances of a severe and even fatal character. The forms 
of marked cardiac irregularity are especially disquieting if observed 
during or after diphtheria, even of a mild type. In these cases the 
physician is ill at ease on account of the well-known occurrence of 
sudden death in this disease. I have seen irregularity persist in these 
cases for weeks, to disappear finally; and yet during all this time the 
physician can give no positive assurance that the case may not result 
fatally. Simple irregularity, as a rule, without signs of true mus- 
cular weakness of the heart, such as swelling of the liver or dilatation 
of the ventricle, retrogrades to the normal. 

The toxic myocarditis complicating diphtheria manifests itself in 
two forms: the slow irregularly acting hearl and the rapidly acting 
organ. In those cases in which the heart-action is rapid, the effect 
of the toxin is manifested in a rapid tumultuous action from the out- 



708 DISEASES OF THE CIRCULATORY SYSTEM. 

set. The pulse is thready, demonstrating the ineffective driving- 
power of the heart and great muscular weakness of that organ. The 
orthopnoea is great and there is swelling of the liver with epigastric 
pain and vomiting. 

In acute forms of pneumonia in which the toxsemia is very great, 
infants may, even at the outset, exhibit cardiac weakness. There are 
slight cyanosis of the lips and abnormal pallor of the face and gen- 
eral surface. The heart action is more rapid than in other cases of 
pneumonia in which the lung lesion is quite as extensive. At the 
crisis, the action of the poison on the heart is evinced by an irregu- 
larity or arrhythmia of the pulse. The pulse may be extremely slow 
(bradycardia). In septic conditions there will, late in the disease.be 
gallop-rhythm, distortion of the pulse-respiration ratio, cyanosis, and 
extreme precordial distress. Henoch, Osier, and the writer have shown 
that there may be degenerative changes in pertussis. These are clini- 
cally apparent in cases which have extended over a long period. A 
constant dyspnoea, an abnormally high pulse-rate, drowsiness, disin- 
clination to exertion, and slight oedema of the face and other parts 
of the body are present. In rare cases physical examination reveals 
a slight dilatation of the right ventricle. In other cases there is at 
the apex a faint systolic murmur of purely muscular origin. In 
adherent pericardium, the advance of the process into the myocardium 
is indicated by the symptoms above detailed. 

The myocarditis of chronic valvular disease is a progressive 
process. It manifests itself by the signs of lack of compensation 
described in the section on Chronic Valvular Disease. The varying 
pulse, the dyspnoea, the enlargement of the liver and spleen, and 
transudates into the serous cavities, all indicate this form of progres- 
sive weakness of the cardiac muscle. 

Diagnosis. — Although the diagnosis cannot in all cases be made 
with absolute certainty, the presence of the condition may be sus- 
pected if the following sets of symptoms appear at regular intervals 
in the course of the disease — attacks of palpitation and faintness, 
pallor, cardiac irregularity, gallop-rhythm and weakness of the apex 
beat and of the first muscular sound of the heart, with intensification 
of the second pulmonic sound. 

Treatment. — The treatment should support the heart and lessen its 
work, and should also be directed toward the management of the 
primary condition. In all of these cases, prolonged rest for the heart, 
continued long after convalescence, is of primary importance. It 
should not be forgotten that even in a degenerated organ there is 
healthy tissue on which the drugs and treatment act. These healthy 
foci should be sustained, and not exhausted by the action of powerful 
drugs given in large doses. Degeneration cannot be cured by drugs ; 
nature must heal the diseased areas. 



DISEASES OF TEE HEART. 709 

Cardiac irregularity, pure and simple, with a pulse of moderate 
slowness, is best treated by means of strychnia and caffeine. To a 
child of three or four years of age, strychnia, %oo grain, is given 
with or without a grain of caffeine every three hours. Warmth is 
applied to the heart, and if the extremities are cold, warm bottles are 
applied also. Camphor is a very excellent remedy, but can only be 
used for a short length of time, for it is badly borne by the stomach, 
and in such cases must be used hypodermically. Oil of camphor. 30 
minims, may be given to a child three years of age. 

Severe cases accompanied by a gallop-rhythm are treated with 
talis. This drug is an excellent remedy in these cases, but must be 
used cautiously, in small doses. To a child of three or four years of 
age, TlXij of the tincture of digitalis given every three hours is suffi- 
cient. If restlessness or vomiting appear, morphia is our only safe- 
guard, but should be used cautiously. Enough only is given to quiet 
the patient. One or two minims of Magendie's solution is given by 
the mouth to a child three to five years of age. 

Hypertrophy and Dilatation of the Heart. — Cardiac hypertrophy 
and dilatation, combined or singly, and without any valvular lesion, 
occur in isolated cases in childhood. The condition is rare before 
the fifth year. A number of cases occurring between the fifth and 
the tenth year have been reported. If hypertrophy alone is present, 
it may affect the left ventricle only, or both ventricles. Dilatation 
usually affects first the right and then the left ventricle. The condi- 
tion develops as a result of toxsemic influences, in the acute infectious 
diseases, such as scarlet fever, pneumonia, diphtheria, and typhoid 
fever. 

Hypertrophy, with or without dilatation, is one of the sequelae of 
acute or chronic nephritis. The nephritis complicating scarlet fever 
is frequently the cause of cardiac hypertrophy with or without dila- 
tation. Arterio-sclerosis with diminution of the calibre of the aorta 
may cause hypertrophy with or without dilatation. I have seen sev- 
eral of such cases in children. Acute dilatation as a result of heart 
strain is rare in children. 

Symptoms. — The symptoms arc not characteristic. In the absence 
of all other heart lesions, the diagnosis of cardiac hypertrophy <>r 
dilatation is made from the physical signs. These do nol differ from 
those found in the adult subject. The rational symptoms also resem- 
ble those of the adult. In dilatation of the heart, there arc the irreg- 
ular heart action, the dyspnoea or orthopnoea, the pallor of the surface. 
cyanosis, and in the later stages swelling o\' the liver and spleen. 
Transudates in the pleura] and abdominal cavities are apt to occur 
toward the close. Sudden death has occurred in some eases of dila- 
tation of the acute variety. In hypertrophy, the symptoms closely 



710 DISEASES OF TEE CIRCULATORY SYSTEM. 

resemble those just detailed. At the bedside, the diagnosis of hyper- 
trophy, of dilatation, or of both, must of necessity rest on the physical 
signs. 

Treatment. — The treatment varies with the nature of the primary 
disease present. The nephritis should be treated and the heart will 
take care of itself. If there is an infectious disease, such as typhoid 
fever, diphtheria, or scarlet fever, both the heart and the primary 
affection should be treated. 



SECTION X. 

GENERAL CONSTITUTIONAL DISEASES. 

DIABETES MELLITUS. 

Diabetes mellitus is of very rare occurrence in infancy and child- 
hood. Simon says that he has met it in nurslings, but Monti doubts 
whether it can occur under the age of one year. In all his experience 
he has never seen such a case. Leroux, quoted by Monti, collected 
147 cases of diabetes in children. The majority occurred between 
the fifth and tenth years. Of 159 cases collected by Saundby, 129 
occurred between these years. Cotton has, in a recent article, shown 
that in children the ratio of deaths from diabetes to the whole death- 
rate is 0.04 per cent, in Chicago, and 1.2 per cent, in New York City. 

Etiology. — The etiology of diabetes in children is practically the 
same as in the adult subject. Frerichs, Blanchard, Pavy, and 
Roberts have shown that heredity plays an important role. In a case 
coming under my observation a sister of the patient had died of dia- 
betes and four members of the family on the mother's side. In an 
instance reported by Roberts, 8 children of the family had died of 
it. It appears that in certain families there is a tendency to con- 
tract diabetes. There is no ground for assuming that diabetes in 
children follows traumatism or the infectious diseases, such as scarlet 
fever, measles, diphtheria, etc., any more frequently than in the adult. 
In some statistics, the sexes are shown to be equally affected. In 
others the disease is given as more prevalent in one or the other. 
Lemonnis has seen diabetes complicate congenital syphilis, tubercu- 
losis of the lungs and of the mesenteric lymph-nodes. I have had a 
case complicated with tuberculosis of the mesenteric lymph-nodes. 

Symptoms. — The symptoms of diabetes in children, as given in the 
cases thus far published, do not extend over so great a period as in 
the adult. The cause of this must lie in the fact that there is a long 
period during which the symptoms are slight or escape notice. In a 
case which recently came under my care the child, nine years of age. 
showed symptoms only five months before she came under observa- 
tion. At that time the mother noticed that the appetite was voracious 
and that there were great thirst and frequent urination. Tn spite of 
the large quantity of food and liquid taken, the child lost in weight. 
The amount of urine passed may be quite large. In Cotton's ease it 
reached 104 ounces, in mine 70 ounces daily. Monti has seen as 

711 



712 GENERAL CONSTITUTIONAL DISEASES. 

much as 16 litres passed in twenty-four hours. Heubner and Hirsch- 
sprung found that the daily excretion of sugar may be from 30 to 113 
grammes to the litre. 

In most of the cases recorded there has been polydipsia. The skin is 
sometimes the seat of a lichen-like eruption which causes intolerable 
itching. Furuncles and boils are also of common occurrence. The 
urine may contain albumin, and hyaline and granular casts. In one 
of my cases albumin was present, but no casts. There is as a rule 
constipation. The temperature may be normal or subnormal. If 
there is complicating tuberculosis, there will be a slight daily rise 
of temperature toward evening. In all the cases thus far published 
there was progressive emaciation. Acetone in the odor of the breath 
and diabetic coma preceded by intervals of delirium close the clinical 
course of the disease. 

Diagnosis. — The methods of diagnosis do not vary from those pur- 
sued in the adult. The urine of a child suffering from polyuria, 
polydipsia, a voracious appetite, pruritus, and progressive emaciation, 
should be carefully examined for sugar. Infants who take foods such 
as malted milk, containing an enormous quantity of sugar, often show 
a temporary glycosuria, which should not be mistaken for true dia- 
betes, and which is not attended by any of the clinical symptoms of 
that disease (Epstein, Koplik). 

Treatment. — The treatment of diabetes in children does not differ 
from that of the adult, but I have been impressed with the necessity 
of keeping these patients in bed during the treatment, as it is impos- 
sible otherwise to observe the patient or follow out details of dietary. 

DIABETES INSIPIDUS. 

(Polyuria.) 

This is rare in infancy and childhood. If the daily amount of 
urine is three or more times the normal amount, there is polyuria. 
The specific gravity of the urine does not exceed 1006. Epstein col- 
lected 10 cases in which the symptoms developed as a result of a 
cerebral inflammation in the vicinity of the fourth ventricle. The 
affection is sometimes hereditary. Cases have followed fright, the 
infectious diseases, meningitis, and traumatism. The cause is fre- 
quently obscure. The onset may be gradual or acute. 

Symptoms. — Sometimes intense thirst or nervous symptoms usher 
in the disease. The nutrition may be maintained for years. The 
skin is dry, the body temperature below normal, and the symptoms do 
not differ from those manifested in the adult. The following case 
from my clinic was published by my assistant, Dr. Lewi : 

Walter A., set. seven years, was first seen at the dispensary. The 



DIABETES INSIPIDUS. 713 

family history was, for the most part, negative, except that three 
children had died of nervous diseases, one of them, aged three years, 
of spinal meningitis, and two others, when babies, of convulsion-. 
The patient when a baby was healthy; he was breast-fed one year 
and had never had a convulsion. When two years old he had vari- 
cella, followed by pertussis ; at the age of five he had measles, compli- 
cated with an obstinate conjunctivitis, but recovered. In October, 
1892, while driving, he was thrown from a carriage in rapid motion, 
striking the right side of the head ; no ill effects were noticed at the 
time. In January, 1893, he began to complain of pain in the back 
and in the nape of the neck. At about the same time it was noticed 
that he arose several times at night to urinate, and would invariably 
drink water after micturition ; the mother noticed that he grew very 
nervous ; the frequent micturition and increased thirst gradually be- 
came noticeable during the day, becoming so persistent that he was 
obliged to leave school. He was placed in a hospital, where he re- 
mained seven months ; while there he lost flesh ; none of the symptoms 
improved. He was on a rigorous milk diet during the entire time. 
January 19, 1894, the child complained of pain on the right side 
of his head and felt chilly all the time and .could not stand still a 
moment. His face is pale and has an old person's look, with features 
sharp and pinched. The eyes are large and prominent, and the veins 



Date. 


Sp. grav. 


Amount in 24 hours. 




Urea. 


Jan. 25. 


1.003 


6.300 c.C 


6.3 


grammes 


Feb. 4. 


1.003£ 


6.300 " 


6.8 


" 


6. 


1.005 


5.200 " 


7.2 


" 


8. 


1.002 


7.000 " • 


6.5 


it 


" 10. 


1.004 


5.500 " 


6.8 


a 


" 17. 


1.002£ 


7.500 " 


7.8 


a 


" 24. 


1.003 


6.400 " 


6.5 


a 


Mar. 18. 


1.003 


7.000 " 


8. 


ti 


" 30. 


1.003 


7.300 " 


7. 


" 


Apr. 2. 


1.003£ 


6.400 " 


6.8 


" 



of the forehead dilated. The skin is exceedingly dry. The head is 
well shaped ; careful palpation shows no sensitive spots. The chest is 
emaciated, with a slight rachitic girdle. The lungs, on auscultation 
give increase of voice-sounds at the right apex. The heart is normal, 
also the abdomen. The epiphyses of the ankles are en la rued. The 
glands at the angles of the jaw are enlarged, also those in the left 
axilla. 

Urinary Symptoms,— The child is passing a very large amount of 
urine; wakens on an average ten times a night to do so. The i hirst 
varies with the aniouni of water passed^ for the last few weeks he 
has complained of painful micturition. His appetite is excellent: 
he is on a milk diet. Weighl is thirty-seven pounds; temperature 
(per mouth) 07. 8° F. (36.5° C). The urine examination was as 



714 GENERAL CONSTITUTIONAL DISEASES. 

follows: quantity in twenty-four hours, 6400 c.c, colorless; specific 
gravity 1.003 ; reaction acid, no albumin, no sugar. Microscopical 
examination negative. 

A series of quantitative urea tests were made in this case. The 
general consensus of opinion is that in cases of diabetes insipidus the 
amount of solids, including the urea, is increased. The tests were 
made with the Doremus ureometer. A control test was always made. 
The table shows marked diminution in the amount of urea. In order 
to avoid error, fresh bromine was used. 

Treatment. — The treatment has been successful in some respects. 
The child was at once put on a general diet. Antipyrin was given. 
After the first few days there seemed to be an abatement of the ner- 
vous symptoms and slight diminution in polydipsia, but no permanent 
improvement. He was then given opium several weeks without result. 
Ergot was next given, and continued for about two months ; under this 
treatment the pain on the right side disappeared; the restlessness 
became less, and the thirst likewise diminished. Under a generous 
diet the child held his own. 



PLATE XXX 



12 




1 



4 



5' 






I 



\l\ 



i. fMm 



mm 



/' 






-i* 



10 



Topography of Enlarged Lymph Nodes. 

1. Preauricular nodes enlarged, with disease of the externa] auditory canal, or any eruption 

on the face, of parotitis 

2. Tonsillar nodes. 

3. Submaxillary nodes enlarged, with disease of the mouth, or skin eruptions over the lower jaw . 

4. Submental nodes enlarged, with chin eruptions, 

5. Retropharyngeal nodes enlarged, with infections o\ the pharynx and the retropharynx. 

6. Nodes behind the border of the trapezius muscle enlarged, with disease of the scalp. 

7. Nodes behind posterior border of the sternomastoid muscle enlarged, with infections of the 

retropharynx or the scalp. 
S. Postaurioular nodes enlarged, with mastoid disease or scalp infections. 

9. Nodes above and behind the clavicle enlarged, with infections of the neck or mediastinum. 
H). Nodes enlarged in infections ,,f the hand or in eruptions such as those o( syphilis. 

11. Axillary nodes enlarged, with infections of the arm. the axilla, and the upper chest. 

12. Nodes of the inguinal region enlarged in infections of the lower extremity, syphilitic or 

other lesions of the genitals. 



SECTION XL 

DISEASES OF THE LYMPH-NODES, DUCTLESS 
GLANDS, AND THE BLOOD. 

DISEASES OF THE LYMPH-NODES. 

In any disease or irritation of the scalp the nodes of the neck may 
be enlarged behind the border of the sternomastoid. The onset of 
some diseases of infancy, such as rotheln or rubella, is indicated by 
slow enlargement of these glands. Infection of the tonsils will cause 
the lymph-nodes at the angle of the jaw to enlarge and sometimes to 
suppurate. In young infants and children, chronic enlargement of 
the tonsils with adenoids causes an enlargement of these nodes. Tu- 
berculous glands may occur in this region. The post-auricular lymph- 
nodes enlarge in disease of the ear or of the adjacent parts of the 
scalp. Parotitis will cause a sympathetic swelling of the lymph- 
nodes in front of the parotid, and also below this gland at the angle 
of the jaw and beneath it. 

Retropharyngeal adenitis will cause the nodes behind the pharynx 
to swell and to appear at either side of the neck in front of the border 
of the sternomastoid muscle. 

Any eruption on the chin will cause an enlargement of the lymph- 
nodes from the tip of the chin to the hyoid bone. 

Swelling at the angle of the jaw will frequently simulate parotitis. 

In certain forms of congenital syphilis with mucous patches on 
the lips and at the angles of the mouth (rhagades) there is beneath 
the body of the jaw a symmetrical enlargement of the lymph-nodes 
of both sides (syphilitic adenopathies). The lymph-nodes of the 
groin will enlarge in balanitis of the prepuce, syphilis, tuberculosis 
of the genitals, and also in eczema and intertrigo of the inguinal 
folds. The lymph-nodes of the femoral region will in infants and 
children enlarge or suppurate as a result of any infection of the foot. 
leg, or thigh. 

In the later stages of tuberculosis, either of the lung or perito- 
neum, there may be a general enlargement of the nodes of the neck, 
axilla, groin, and elsewhere. In nmny infants and children of a 
lymphatic diathesis (lymphatism), the nodes of the nock and groin 
show slight enlargement. Such enlargements should not, in the 
absence of positive signs oi' tuberculosis elsewhere, be hastily pro- 
nounced tuberculous. After the exanthemata, the lymph-nodes of the 

715 



716 LYMPE-NODES, DUCTLESS GLANDS AND BLOOD. 

neck, groin, and other regions may remain slightly enlarged. These 
enlargements usually retrograde to the normal in time, but if they 
remain rarely give rise to symptoms. 

The physician should exclude every possible infection before con- 
cluding that an enlargement of the lymph-nodes in infancy and child- 
hood is of a tuberculous nature. Cases of rachitis will show very 
slight enlargement of the lymph-nodes, especially in the inguinal 
regions. Forms of anaemia, such as von Jaksch's disease, also show 
these enlarged nodes. The lymph-nodes may be the seat of primary 
malignant disease, as in forms of lymphosarcomata. In malignant 
growths of the internal organs, such as the kidney, etc., they may be 
the seat of metastatic deposit. They are enlarged in acute and 
chronic forms of leukaemia and Hodgkin's disease. In these diseases 
the spleen and liver are also enlarged. 

Acute Adenitis (Acute Lymphadenitis). — The lymph-nodes in 
infants and children are peculiarly susceptible to acute infections, 
which are for the most part pyogenic (staphylococcic and strepto- 
coccic). Yan Arsdale collected 500 cases of acute lymphadenitis 
seen by him. He found that 77 per cent, of them were in children. 
They are especially liable to the cervical infections. Eighty-five per 
cent, of the cases in children were infections of the lymph-nodes of 
the neck, the frequency in adults being only half as great. 

Etiology. — Most of the infections of the lymph-nodes in children 
are, according to Yan Arsdale, acute (79 per cent.). The majority 
of them are pyogenic. Children are subject to acute infections of 
the scalp, face, mouth, nose, tonsils, and mucous membrane of the 
nasopharynx. The lymph-nodes draining these regions are in the 
direct line of infection. Thus eczema and skin eruptions of all kinds, 
stomatitis of all varieties and inflammation of the tonsils and the 
nasopharyngeal space, will give rise to enlargement of the lymph- 
nodes. If the infection is severe, suppuration occurs. It is owing 
to these causes and to the breaches of surface caused by slight trauma- 
tism that this form of adenitis is so common. The essential exciting 
cause of acute lymphadenitis is the invasion of the nodes by pyogenic 
bacteria entering through the lymph-channels. 

Symptoms. — The symptoms of lymphadenitis in infants and chil- 
dren are essentially the same as in the adult subject. The node is at 
first felt as a hard nodular mass beneath the skin. One node or sev- 
eral may be infected. There is always some fever. At first the skin 
over the node is of normal color, but, as the inflammation progresses, 
it becomes involved, red, and finally there develop all the signs of an 
ordinary abscess. 

Diagnosis. — The diagnosis is not difficult. The history and gen- 
eral course at once point to the nature of the disease. When the 



DISEASES OF THE LYMPH-NODES. 717 

region about the parotid is affected, it is at times difficult to tell 
whether there is an infectious parotitis, or whether the nodes just 
beneath or above the parotid are involved. A preauricular gland 
situated in front of the ear on the parotid gland is apt to enlarge and 
suppurate. The nodes underneath the angle of the jaw and in front 
of the border of the mastoid sometimes enlarge and suppurate, in- 
volving the parotid by collateral swelling. In all of these cases, it is 
important to remember that a line drawn parallel to the lower border 
of the body of the jaw marks off the parotid above, and the lymph- 
nodes below. In exceptional cases, the swelling of infections parotitis 
may extend lower than this line. 

Treatment. — The treatment of acute lymphadenitis is at first abor- 
tive. Cold applications to the nodes which are enlarged and access- 
ible, such as those of the neck, relieve the pain and in many cases 
lessen the severity of the reaction. This result is frequently seen in 
cases where infection of the nodes of the neck results from tonsillitis. 
Sometimes, in spite of all that can be done, suppuration occurs as a 
result of infection of cervical, axillary (vaccination), and inguinal 
nodes. In that case, the affected node should be incised. The further 
treatment of such cases is surgical. 

Chronic Lymphadenitis. — Chronic or subacute enlargement of 
the lymph-nodes in children may be pyogenic, tuberculous, or syphi- 
litic. Of the cases collected by Van Arsdale, only 21 per cent, in 
infants and children were of chronic pyogenic origin, as against 12 
per cent, in the adult. On the other hand, only 6 per cent, of all the 
cases of adenitis in infants and children were tuberculous. In the 
adult, the tuberculous forms of lymphadenitis are twice as frequent 
as in children. It is thus seen that even in chronic enlargements of 
the lymph-nodes of infants and children the occurrence of tuberculous 
forms gives the lowest percentage. 

Symptoms. — The symptoms of chronic enlargement of the lymph- 
nodes in infants and children are nodular tumors corresponding to 
the affected lymph-nodes. The enlargement may be single or mul- 
tiple. Sometimes a whole packet of nodes is enlarged. The nodes 
most commonly enlarged are those at the angle of the jaw. This 
occurs. in infants and children who suffer from chronically enlarged 
tonsils and adenoids. As a rule the nodes affected remain enlarged 
for months. At times they are somewhat less swollen. They do not 
suppurate unless there is a tendency to a breaking-down of tissue. 
In all of these cases there is not only toxic irritation, but also a true 
hyperplasia of the tissue of the glands. 1 have seen these nodes 
removed and opened. Some of them have a soft, broken-down centre 
resembling that oi' the tuberculous nodes. 

Treatment.- -The treatment of chronic lymphadenitis is directed 



718 LYMPH-NODES, DUCTLESS GLANDS AND BLOOD. 

toward removing the source of infection. If the tonsils are enlarged 
and adenoids are present, they should be removed. A tonic course 
of treatment, good food, out-of-door exercise, iron, and cod-liver oil 
is indicated. In spite of these measures many cases do not improve. 
If the enlargement of the nodes in such cases is localized, the question 
of the advisability of removing them arises. That measure should 
not be resorted to unless there is a reasonable certainty that they are 
tuberculous, and when all other treatment has failed. 

DISEASES OF THE THYROID GLAND. 

General enlargement of the thyroid is not uncommon in infancy 
and childhood. Normally the thyroid gland, and especially its isth- 
mus, can be made out only by careful palpation. The isthmus is 
indicated by a very slightly raised structure passing across the trachea 
beneath the cricoid cartilage. The lateral lobes cannot be palpated, 
except in cases in which these lobes are enlarged or where there are 
subsidiary thyroid masses. In endemic cretinism and in some forms 
of the sporadic type of cretinism and in cases of dwarfs in goitre dis- 
tricts, the enlarged lateral or supernumerary lobes beneath and just 
in front of the anterior border of the sternomastoid muscle can be 
palpated. Cystic growths of the thyroid are seen in front of the 
trachea, generally just above the notch of the sternum. They may 
occur in very young infants or in children of four or five years of 
age. Enlargement of the isthmus occurs chiefly in girls (Fig. 148). 
In these cases there is a disturbance of the heart functions and symp- 
toms of the onset of morbus Basedowii. 

Cretinism. — Cretinism is a chronic affection which is character- 
ized by a defective growth of the bones of the skeleton in their long 
axes, accompanied by a distinct set of mental symptoms and by 
changes in the soft parts: There are two forms, the endemic and 
the sporadic. 

Endemic Cretinism. — Endemic cretinism occurs in certain dis- 
tricts of Continental Europe. It does not exist in this country 
(Osier). The pictures presented by endemic and sporadic cretinism 
are similar. According to the recent studies of Dolega, His, and 
Bernard, their pathologic anatomy is also similar. Endemic cre- 
tinism is an advanced stage of a degeneration beginning with goitre 
manifestations. The resulting changes are due to " athyreosis,'' a 
suspension or disturbance of the functions of the thyroid gland. 
Sporadic cretinism, although also due to athyreosis, occurs without 
goitre. The peculiar formation of the skull in cretinism, endemic or 
sporadic, is now known not to be due to a premature synostosis of the 
os basilare and the sphenoid, as was at first thought by Virchow. The 



DISEASES OF THE THYROID GLAND. 



719 



brachycephalic skull as manifested in a broadening of the bridge of 
the nose, and the prognathous expression are due to a deficient growth 
of the bones at the base of the skull, in their long axes. The sutures 
and fontanelles remain open for a long time. Dentition is delayed, 
The skin is myxedematous in sporadic cretinism only. Dwarfism 
and anamria are common to both forms. 

Fig. 163. 




Enlarged thyroid in a child. 

Sporadic Cretinism.— Occurrence. — The disease may appear in 
utero or at any time after birth. Fully one-half of the cases develop 
before the eighteenth month (Fletcher Beach V 

Symptoms. — I have published cases in which the symptoms were 
evident within a month or five weeks after birth. The history was 
as follows: In one case there was another cretin in the family; in 
the others there was no such history. The birth as a rule was nor- 
mal (Fig. 149). The infant was jaundiced, but fairly well nour- 
ished. It lay in a torpid state and was only roused when severely 
teased. The infant was easily chilled. The cry was deep ami coarse. 



720 LYMPH-NODES, DUCTLESS GLANDS AND BLOOD. 

The forehead was low and narrow. The eyelids were puffy. The 
tongue was large, broad, and thick, at times protruding from the 
mouth. The abdomen was large, and the thighs and legs were out 
of proportion to the length of the trunk. The skin had a greenish 
hue. The thyroid gland could not be found. The surface was cool 
and the rectal temperature 97° or 97.8° F. (36.1°-36.5° C). The 
blood in these early cases has foetal characteristics. There isnoleuco- 

FiG. 164. 




Congenital sporadic cretinism. Infant, four weeks old. 

cytosis. In the cases which develop some months after birth the 
infant may at first be bright and normal. Six to nine months after 
birth it may have had some slight illness, such as an adenitis, and 
after this the change was noticed, or the change may have occurred 
without any preceding illness. The infant ceases to notice objects 
about it, and becomes stupid and weaker. It may previously have 
attempted to walk or stand, but ceases to make an effort to do so 
( Plate XXXI. ). The child's expression is idiotic. It has a mean- 
ingless smile most of the time and does not play. The skin has a 
wrinkled and myxoedematous appearance, the color being not only 
pale, but also greenish. The nose is flattened, the lips are thickened, 
and the hair becomes dry and sparse. The forehead is narrow and 



PLATE XXXI 



P*% 




Sporadic Cretinism. Child fifteen months o 



DISEASES OF THE THYROID GLAND. 



72] 



the face has a prognathous expression — " monkey-like/' as one mother 
expressed it. There are no teeth. The neck is short and thick. 
The genitals are large for the age. The skin of the scrotum is thick- 



Fig. 165. 




Sporadic cretinism; myxcedema marked, child, twenty months of age. 



ened. The anaemia in these cases is extreme. The haemoglobin may 
be as low as 18 per cent. The leucocytes may be as Inch as 18,000, 
and the red blood-cells 5,600,000, 

4(5 



722 



LYMPH-NODES, DUCTLESS GLANDS AND BLOOD. 



In other cases, the symptoms are at first more of the myxede- 
matous type. The skin, especially that of the face, has a greenish- 
yellow, waxy, puffy appearance. The upper and lower eye-lids are 
swollen, as in nephritis. With these appearances, there are the dry 
hair, the macroglossia, the guttural voice, the dwarfish appearance, 
the protuberant abdomen, and the mental dulness. The expression 
of the face is less prognathous than in the first form. In one of my 
cases the infant was in good health until the sixteenth month. It 
then developed abscesses over the body, after which the symptoms of 
cretinism were noticed. The abscesses were peculiar, the granula- 

Fig. 166. 




Cast of the hand of a boy cretin, four years of age. Flat and spade-like in form ; it 
shows also the thickened and hypertrophied hypothenar eminence. 



tions sluggish, and the pus was creamy. The skin was not oedema- 
tous, but myxoedematous. 

In both forms the hands are large, flat, and spade-like. The 
hypothenar eminence is thick, square, and hypertrophied, as in the 
lower animals (Koplik and Lichtenstein) (Fig. 166). In some cases 
the thyroid gland cannot be felt, in others it is' small, and in excep- 
tional cases there is goitre (7 cases of Osier's series). In some cases, 
supraclavicular masses of fat or fatty tumors behind the sternomastoid 
muscles are apparent. I have seen these masses of fat in cases which 
had suffered a return of symptoms after suspension of treatment. 

Etiology. — The etiology of sporadic cretinism is as yet absolutely 
unknown. Experimental and operative pathology have demonstrated 
that interference with the function of the thyroid gland (athyreosis) 
will produce a condition (myxoedema) closely resembling cretinism 



DISEASES OF THE THYROID GLAND. 



723 



(Horsely, Reverdin, Kocher). The essential cause of endemic cret- 
inism is thought to be some form of infection (Fagge). Sporadic 
cretinism is also ranked by some authors among the infections. 

Morbid Anatomy.- — There are cases of sporadic cretinism in which 
the thyroid gland is absent. It has not developed in foetal life and 
is not found at autopsy. In other cases there is found at autopsy 
a small atrophied gland which is sclerosed and much reduced in size. 
Such cases have been published as following the infectious diseases. 



Fig. 167. 




Cretin, myxedematous typt 



Lastly, there are cases with goitre. The changes in the thyroid, when 
it is found in sporadic cretinism, have been described by Barker. 
There is an increase of connective (issue. The parenchyma is re- 
placed by small and large irregularly shaped cells, which are granular 
and unlike the normal tissue. Seme of the acini are almost solid : 
others are cystic and filled with colloid material. The cells may con- 
tain vacuoles: their nuclei may show " karyorrhexis." The nuclear 



724 LYMPH-NODES, DUCTLESS GLANDS AND BLOOD. 

changes are characteristic of degenerative processes. Some of the 
acini are replaced by connective tissue. 

The Bones. — In the recent work of His, Dolega, and Bernard, it 
has been clearly shown that ossification in the pre-existent cartilagi- 
nous structures of the skeleton is delayed in all its phases. This is 
evinced in the delayed appearance of ossification centres, the delayed 
bony transformation of the epiphyses, and in the persistence of the 
epiphyseal zones. In some cretins, ossification is completed at a very 
late period of life ; in others, infantile conditions are perpetuated. 
The dwarfing of the whole skeleton is thus explained, not by a pre- 
mature synostosis, but by faulty proliferation and ossification of the 
epiphyseal cartilages. The bones of the skull are affected in the 
same manner as the vertebrae and the long bones, in that they fail 
to grow in their long diameters and in that ossification centres 
appear late. 

Diagnosis. — The diagnosis is not difficult in advanced cases. The 
early cases require close study. In these, the stupidity increasing to 
absolute idiocy, the retarded growth, the change in the expression, the 
swollen eyelids, thick lips, dry hair, wrinkled myxedematous skin, 
the flat, spade-like hands, the dwarfish appearance, and the reduced 
internal temperature, all point to the diagnosis. In later cases, the 
extreme anaemia, myxedema, and pronounced prognathous expression 
of the face are apparent. 

Differential Diagnosis. — Mongolian Idiocy. — This is a form of 
genetous idiocy with which cretinism is frequently confounded. The 
idiots resemble cretins. The growth is stunted. The mouth is kept 
open. The f acies seen in cases of adenoids is present but due in these 
cases to peculiar bone formations at the base of the skull. The tongue 
is large and fissured ; the papille of the tongue are enlarged and erect. 
The tongue protrudes from the mouth (Plate XXXII.) ; the lips are 
thick; the voice is coarse and guttural. The temperature may be 
subnormal, but is generally normal. The skin is dry and the hair 
coarse. In young infants the skin may be delicate. The patients are 
easily chilled. The musculature is flabby. The infants cannot hold 
the head erect. The occiput is flattened, the neck short and thick. 
There is strabismus, and the axes of the eyelids have a Mongolian 
slant — that is to say, they converge. The inner eyelid comes down 
toward the nose with a rapid slope. The bridge of the nose is flat. 
The head is small and obtusely rounded; the antero-posterior diam- 
eter is nearly equal to the lateral one. The fontanelles remain open 
late. The skin, however, is not myxedematous, nor is the expression 
prognathous as in the cretin. The anemia is as a rule marked; in 
some cases the skin has a greenish hue. There is a curving inward 
of the tip of the little finger. The second phalanx is short and the 



PLATE XXXII 




Mongolian Types of Idiocy. Infant and young children. 



DISEASES OF THE THYBOID GLAND. 72o 

terminal phalanx displaced. West has shown that although this 
deformity is very common in these idiots, it is not pathognomonic of 
Mongolian idiocy. Many of the subjects of this form of idiocy grow 
to adult life and have varying degrees of intelligence. 

The Dwarf with Idiocy. — There may be several of these dwarfs 
in a family. The thyroid gland is enlarged at the beginning or 
during the course of the condition. The mental state is much stunted. 
The general growth of the body is retarded. Dwarfs are, however, 
well formed. The hands and extremities are perfect and the skin is 
not as a rule myxedematous. 

Infantilism. — Infantilism combined with lipomatosis may be con- 
founded with cretinism. In this form of disease there is no myx- 
edema and the skin is very delicate and soft. The genitals are 
atrophied. The expression of the face is that of child-like simplicity, 
the forehead is low and narrow. The hair is dry, and does not grow ; 
the finger-nails do not grow. There may be, as in the case I pub- 
lished, blindness. The mental state is one of mild idiocy. 

Treatment. — The treatment of cretinism constitutes one of the mar- 
vellous chapters of modern medicine developed by experimental path- 
ology. The administration of thyroid extract results in a partial 
restoration of the mental capacity and a return to growth and develop- 
ment approaching the normal. The writer published in 1897 some 
cases of cretinism diagnosed early in infancy, in which the treatment 
was begun at once. In those in which the treatment was begun at 
the age of one month, the children have become bright and apparently 
normal. In those in which it was inaugurated at the fifteenth month, 
the children have, after five years of treatment, remained somewhat 
backward in mental development. One patient, now a boy of six 
years, goes to school, and recites his alphabet, but is very simple in 
manner. In these late cases the treatment does not give the complete 
results at first expected. 

Treatment is begun by the administration of the dried extract of 
thyroids of sheep, grain -J- (0.03) t. i. d., and increase the dose until 
the infant takes grain j (0.06) three times daily. After the symp- 
toms have retrograded, the dosage is kept stationary for a few months. 
It is then reduced or the remedy is given only every other day. If 
symptoms, such as stupidity, pallor, or reduced temperature reappear, 
the dose is increased. The first sign of improvement is a reduction 
of the anaemia, as evidenced in the increase of haemoglobin. The 
body temperature rises to the normal. The skin becomes o\' normal 
delicacy and supple. The stature increases and the hair becomes 
glossy. Thomson, of Edinburgh, has published cases of adult cretins 
whose bones became softened after the prolonged administration of 
thyroids. These were cases in which treatment was begun late in 



726 



LYMPH-NODES, DUCTLESS GLANDS AND BLOOD. 



life. The symptoms of excessive administration of thyroids include 
rise of temperature and slight diarrhoea, due to toxins in the thyroids. 
I have found thyroid therapy of doubtful utility in cases of Mon- 
golian idiocy. In the dwarfs above mentioned, it causes increase of 
stature ; the intelligence, however, remains backward. 

Fig. 1(58. 




Infantilism and lipomatosis universalis in a boy ten years of age. 



Dwarfism; Nanism. — A dwarf is a person of very small stature. 
The tallest dwarf according to Sainton should not exceed 1.5 metres 
or 59 inches in height. 

Differentiation from Infantilism. — Infantilism is frequently con- 
founded with dwarfism, but it is the direct opposite of the latter con- 



DISEASES OF TEE THYROID GLAND. 727 

dition. Meige defines infantilism as a physical and mental condition 
found in individuals whose sexual apparatus is congenitally or acci- 
dentally in a state of arrested development. Infantilism is charac- 
terized by rounded face, dimpled features, gracile limbs, prominent 
lips, smooth skin, fine, clear complexion, delicate hair, slightly marked 
eyelashes and eyebrows, small nose, long torso, prominent abdomen, 
and a rounded obese conformity of the body (Fig. 168). There is 
an absence of hair on the pubes and axillae, the mental state is that 
of childhood and the stature is not that of a dwarf. They are not 
vicious, though at times moved to anger. An excellent example and 
portrait of this condition is given elsewhere. 

Dwarfism, on the other hand, is an arrest of development. The 
mental state varies ; at times dwarfs are quite clever. 

Varieties.- — Sainton describes dwarfs as: 

1. Myxedematous dwarf s. 2. Achondroplasic dwarf s. 3. Rachitic 
dwarfs. 4. Spondylitic dwarfs. 5. Anangioplastic dwarfs. 6. 
Pygmies and dwarfs with lesions of the suprarenal capsules. 

1. The myxcedematous dwarfs are quite numerous, the head is 
large, the face puffy, complexion yellow, skin thick, the genitals 
atrophic, the thyroid absent or scarcely perceptible, and the voice 
thin and high-pitched. The thyroid and glands supplying internal 
secretions are in a state of atrophy. Thus there is an etiological 
factor in this atrophy. The mental condition is not as bright as in 
other forms of dwarfism. 

2. The achondroplastic dwarfs are elsewhere described. They 
are brighter than the above class. Their characteristics have been 
described by Pierre Marie. The arrest of development is most appar- 
ent in the lower extremities, the trunk and arms being almost normal. 
Micromelia is a term at times applied to this condition. 

3 and 4. Spondylitic and rachitic dwarfs are not as frequent. 
The former condition depends on a curvature of the spine and a 
rigidity of the cervical vertebrse. 

5. Anangioplastic dwarfs are most uncommon. They are per- 
fectly formed, small, graceful individuals. I have seen several ex- 
amples of this type and have described them. 

6. Pygmies described by Poncet and Levair as having an absence 
of physical abnormalities, bodies are small but harmoniously devel- 
oped; such are the dwarfs of the Eskimos, Laplanders, Fuegians, and 
Central Africa. 

Dwarfism is therefore a condition of mal-development dependent 
in many cases on nial-nulrition or a lack of the internal secretions. 



728 LYMPH-NODES, DUCTLESS GLANDS AND BLOOD. 

DISEASES OF THE THYMUS GLAND. 

Landmarks. — The thymus is a glandular organ enclosed in a cap- 
sule. It is situated in the anterior mediastinum, and contains in its 
structures a white tenacious fluid substance which is present in vary- 
ing quantities. Sappey shows that the thymus in the newborn infant 
extends from the upper edge of the manubrium sterni, 5 cm. down- 
ward. Its upper border may reach the isthmus of the thyroid or may 
be removed 2-J cm. from it. It extends downward to the middle or 
upper third of the pericardium. In exceptional cases it may have a 
longitudinal diameter of 11^ cm., reaching the diaphragm (Triese- 
thau). The thymus is about 2 to 3 cm. wide. Luschka makes it 
unsymmetrical, consisting of two lobes united by an isthmus. It lies 
over the course of the pulmonary artery and is surrounded by a reflec- 
tion of the pericardium. It is separated from the sternum by loose 
connective tissue. Its length varies from 4 cm. in the nursling, to 
11 cm. in the ninth year, the average ratio to the body length being 
1 to 7 or 8. 

Weight. — Its weight varies. In the results which the writer 
obtained in collaboration with Jacobi, it did so within wide limits. 
In infancy the average weight is 20 grammes ; from the second to the 
fourteenth year it is 24 grammes. After the twenty-fifth year the 
thymus atrophies and may weigh 2.2 grammes (Friedeleben). In 
abnormal states the weight may be 32 grammes (Triesethau, Pott). 
The causes of the enlargement of the gland and the conditions under 
which it occurs are not as yet known. The gland is large in infants 
dying of the most diverse diseases. 

Percussion. — Under the most favorable conditions it is difficult 
to ascertain the exact size. The thymus has sometimes been marked 
out as large during life, and post mortem found to be small. As a 
rule, an area of dulness situated behind the upper part of the sternum, 
and discernible on gentle percussion, may be cautiously interpreted 
as due to the thymus (Sahli). An unsymmetrical area giving dul- 
ness on one side of the sternum is probably due to the thymus 
(Luschka), especially in subjects under the second year. The thymus 
may be seen by x-raj as a shadow behind the upper sternal region. 

Abnormal Conditions. — None of the abnormal conditions of the 
thymus can be diagnosed with certainty during life. 

Hypertrophy of the Thymus Gland, Including So-called ' ' Thymus 
Death." — Simple hypertrophy of the thymus gland, irrespective of 
its presence as a cause of sudden death, has been observed by Yirchow, 
Grawitz, Jacobi, and others. It may exist without causing any 
symptoms, and only be discovered postmortem in children who have 
died of various diseases. In other cases an enlarged or hypertrophied 
thymus has been described as causing a series of symptoms similar 



DISEASES OF TEE THYMUS GLAND. 729 

to what is seen in the adult subject in forms of asthma. Virchow, 
Grawitz, West, and Goodhardt have described such cases under the 
head of " Thymic Asthma." These cases are attended with par- 
oxysms resembling those of laryngismus stridulus with difficult 
breathing. Some of the cases described by the above authorities have 
eventuated in convulsions and sudden death. Recently Hochsinger 
has attempted to revive the term " thymic asthma" as applying to 
cases of laryngeal stridor; the symptom-complex in such cases being 
due, in his opinion, to an enlarged condition of the thymus. 

There has been much discussion as to the existence of such an 
entity as " thymic asthma." 

There is another form of sudden death, the so-called " thymus 
death," which has been ascribed to hypertrophy of the thymus gland. 
These cases have been described by Virchow, Grawitz, Pott, and 
others, and there seems to be a tendency in some quarters to attribute 
certain cases of sudden death to the existence of an enlarged thymus. 
In one case, described by Pott, the thymus weighed 32 grammes, was 
9 cm. long and 1^ cm. thick. Cases of thymus death have been 
described, for the most part, in children who are the victims of a 
condition known as status lymphaticus. This condition should be 
differentiated from that described under the heading of Scrofulosis, 
and for the sake of clearness will be described under the head of 
Status Lymphaticus combined with that of thymus death. 

In the work of Jacobi it was shown that hemorrhages of the 
thymus are not uncommon, and are present in a number of conditions, 
especially in pertussis. Inflammation of the thymus may be present 
in inflammatory conditions of the pleura and pericardium. Steu- 
dener has published a case of sarcoma of the thymus, and Yogel one 
of carcinoma of that organ, occurring in childhood. Demme pub- 
lished a case of isolated tuberculosis of the thymus. In the mono- 
graph of Jacobi, general tuberculous infection of the thymus was 
investigated, as was also the condition as found in diphtheria. In 
the latter disease necrobiosis of the thymus was found as described 
by Oertel in other organs. Congenital syphilis may manifest itself 
in arterial and connective-tissue changes. Abscess of the thymus 
is rare. 

Status Lymphaticus (Lymphatism; Lymphatic Constitution). — 
This condition is found chiefly in children who are subjects of rachitis 
and are moderately well nourished but anaemic. They have enlarged 
lymph-nodes at the angle of the jaw, in the axilla, and in the groin, 
and may have all neks of laryngismus stridulus. They have enlarged 
tonsils, adenoid tissue in the posterior nares, and enlargement of the 
adenoid tissue a1 the base of the tongue. On the other hand, they 
presenl none o( the skin-, bone-, and joint-affections seen in the scrof- 



730 LYMPH-XODES, DUCTLESS GLAXDS AND BLOOD. 

Tilous or tuberculous subject. Escherich has published cases in which 
there were 30 attacks of laryngospasm a day. The patients also have 
symptoms of increased excitability of the peripheral motor nerves, 
such as Trousseau's phenomena and Chvostek's symptom. I have 
had one case in which there was an attack of laryngismus at every 
crying-spell. The patients are in constant danger of sudden death. 
The reader is referred to the article on tetany for a further discussion 
of these cases. In rare cases in which sudden death has occurred an 
enlarged thymus has been found, and other lesions which will now 
be described under the title of Thymus Death. 

Thymus Death. — There are two distinct sets of cases of sudden 
death in which the thymus has been found to be enlarged. The first 
are those in which, postmortem, absolutely no other change has been 
found than the presence of an enlarged thymus. In these cases the 
viscera were said to be absolutely normal, but, as has been stated else- 
where, there were evidences of lymphatism, such as enlarged tonsils, 
lymph-nodes, and solitary follicles in the intestine. 

The second set of cases is that in which the thymus was found 
not only to be enlarged, but apparently pressing on the trachea or 
arch of the aorta, causing complete obliteration of these organs. The 
latter set of cases were recorded by Beneke, Lange, and "Weigert. 
But few of these cases published are to be considered in the category 
of thymus death, for these rather represent pathological growths of 
the thymus similar to any other tumor which might lead to pressure 
effects. Such a condition of the thymus is exceedingly rare. What 
interests the physician most, especially as the cause of sudden death, 
are the cases of enlarged thymus in which, as in the first set, no signs 
of pressure were found, either on the large vessels or the bronchi. 
That death in these cases is not caused by pressure is now generally 
conceded. 

The theory advanced by Paltauf and Escherich is not unreserv- 
edly accepted by all. Paltauf contends that the sudden death is due 
to an anomalous lymphato-chlorotic constitution, the enlarged thymus 
thus being only one of the manifestations of a general disturbance of 
nutrition, in which we also find enlarged lymph-nodes and tonsils, and 
hyperplasia of lymphatic tissue. Under the influence of this condi- 
tion there are changes in the nerve-centres of the heart, as a conse- 
quence of which the least excitement may result in fatal paralysis. 
Escherich, in addition, while accepting. this theory, thinks that in the 
condition of lymphatism there is an auto-intoxication whereby the 
nervous system is in a state of morbid irritability and instability 
which results in heart-syncope. In this condition the functions of 
the thymus are probably disturbed, much like that of the thyroid in 
mvxoedema or Basedow's disease. 



DISEASES OF THE THYMUS GLAND. T>\\ 

On the other hand, Eichter has analyzed all the oases published 
of the so-called thymus death. In most of these cases there were 
present anatomically other conditions, such as bronchitis, intestinal 
catarrh, or some other disease, to account for the fatal issue. In 
most children overtaken by this form of death there is a condition of 
lymphatism, and this, in addition to the growing thymus, which at 
the age of two years is quite large, has been made accountable for the 
death of these infants and children, whereas close study will always 
reveal some other morbid condition fully equal to causing this issue. 
Thymus death is one of the rarer forms of sudden death in early 
infancy, as compared with other forms. I have seen it twice, and 
know of nothing more distressing than such an occurrence. The 
physician may be examining such a child for a slight movement, when 
suddenly the infant throws the head backward, there is a noiseless or 
snappy inspiration, the eyes turn upward and sideways, the pupils 
dilate, there is cyanosis both of the face and tongue as the latter be- 
comes swollen and caught in the jaw; there is a convulsive contrac- 
tion of the body backward. There are several inefficient, noiseless, 
shallow inspiratory movements, the body then relaxes, the face be- 
comes ashy pale, and the infant, within one or two minutes, is dead. 
The heart ceases to beat at the beginning of the attack. It is really 
a syncopal death. Escherich has recently grouped these cases under 
the category of tetany or latent tetany. 

There is another form of death in lymphatic infants and children 
which occurs in chloroform narcosis. In such cases the heart may 
suddenly cease to beat during the narcosis; or, as in one of my cases, 
the child may have withstood the narcosis, though it was noticed to 
have taken the chloroform badly. Twelve hours after the operation 
— which in this case was one of appendicitis — the temperature rose 
slightly, there was a rapid increase in the heart action, the pulse 
mounting in a short time so that it could no longer be counted ; while 
the heart beat at the rate of over 200 a minute (cardiac paralysis). 
the pulse could not be felt at the wrist. Death occurred with all the 
signs of paralysis of the cardiac ganglia. 

In the case last described the child was extremely lymphatic, had 
a thymus enlarged to percussion, and a year previous had been oper- 
ated on for adenoid vegetations and enlarged tonsils. The lymphatic 
nodes throughout the whole body were enlarged. The appendicitis 
from which the child suffered was one of the mild catarrhal type. 
There was no septic peritonitis. 

Treatment.- Inasmuch as death supervenes in these eases before 
anything can be done in an orderly way, it is almost superfluous 10 
speak of treatment. Toil, however, and others have performed 
tracheotomy in these eases with a view not only of relieving the 



732 LYMPH-NODES, DUCTLESS GLANDS AND BLOOD. 

spasm of the glottis, which in some instances is present, but of per- 
forming artificial respiration. Others have intubated. In those cases 
in which the heart has ceased to beat, we can scarcely expect to revive 
its action. In one case of my own of a lymphatic child in which the 
heart failed at the outset of the chloroform narcosis, became irregular, 
and threatened to stop beating, artificial respiration, the Laborde 
method of resuscitation, and massage over the cardiac area according 
to the method described by Maas, brought the child to life again. 
We will not always succeed in this manner. 

The treatment of the general condition — the status lymphaticus — 
consists in the removal of the enlarged tonsils and adenoids. In 
these cases the condition of the lymphatic-node enlargements is vastly 
improved by the operation. Good food, cod-liver oil, and the prepa- 
rations of the iodide of iron are also indicated. 

Morse has recently suggested in cases of laryngismus with attacks 
of dyspnoea, the removal of the thymus if the organ was enlarged. 
Two cases thus treated were relieved temporarily, but the symptoms 
ultimately returned and the patients died. 

DISEASES OF THE SPLEEN. 

Anatomical. — At different periods of childhood the length of the 
spleen varies from 4 to 10 cm., the breadth from 2 to 5 cm., the aver- 
age thickness being about 0.5 cm. It forms an oval-shaped body, 
behind the ninth, tenth, and eleventh ribs, the long axis running in 
the direction of the ribs. Up to the second month of life, the anterior 
edge of the spleen is found in the midaxillary line ; after that, it may 
be found further forward than this line, or posteriorly to it. The 
upper edge corresponds to the upper edge of the ninth rib ; the lower 
border to the lower border of the eleventh rib. The spleen may be 
located by percussion and palpation. 

Percussion. — The patient is caused to lie on the back. It is not 
necessary to cause children to lie in an inclined lateral posture. The 
upper border is first located by percussing from above downward in 
the midaxillary line on the left side. At the seventh rib is a strip 
of slight dulness extending from the seventh to the ninth rib. I have 
been able to locate it in infants and in children under the age of six 
years. There can be no question as to its existence, although there 
may be doubt as to its causation. Symmington, in his frozen section, 
shows that, in a girl six years of age, the left lobe of the liver is dis- 
tinctly on the left side behind the seventh and ninth ribs. Sahli 
ascribes the strip to what he calls the deep dulness of the spleen. 
From the ninth rib downward, there is absolute dulness, then flatness, 
due to the presence of the spleen proper behind the chest wall. The 



DISEASES OF THE SPLEEN. 



733 



anterior border of the spleen is located by percussing in a horizontal 
direction toward the axillary line along the tenth rib. 

Palpation. — The enlarged spleen can be distinctly made out by 
palpation. The abdomen should be relaxed. It is sometimes neces- 
sary to flex the thighs slightly, in order to relax the abdomen. In 
young infants this is not necessary. 

The physician stands at the right side of the patient and with 
the palmar surface of the fingers of the right hand palpates the ab- 
dominal parietes just beneath the border of the ribs (Fig. 169). As 
the patient inspires deeply, the hand is by steady pressure insinuated 
beneath the ribs in an upward and backward direction. In the vast 
majority of cases under the tenth year, the normal spleen may thus 
be felt. 

Fig. 169. 




Method of palpating the spleen. 



In practice, it may safely be said that a spleen which cannot be 
felt below the border of the ribs is not enlarged, unless some con- 
dition, such as the presence of fluid or tympanites, prevents thorough 
palpation. I have rarely failed to palpate the enlarged spleen satis- 
factorily. Enlargement of the spleen is found in rachitis, chronic 
^■astro-enteritis, sepsis, typhoid fever, malarial fever, varicella, syph- 
ilis, ansemia infantum pseudoleuksemica, leukaemia, Hodgkin's dis- 
ease, congenital syphilis, cirrhosis of the liver, amyloid degeneration, 
heart disease, and simple catarrhal jaundice. 

From these statements it will be seen that enlargement of the 
spleen in infancy and childhood is pathognomonic o( no one disease. 
and should not lead to any one conclusion. It is only corroborative 
in the presence of other signs and symptoms. Without a very thor- 
ough and painstaking examination o( the Mood, the significance oi 
the enlarged spleen in the febrile and afebrile affections cannot be 



734 LYMPH-NODES, DUCTLESS GLANDS AND BLOOD. 

determined. In enlargements of the spleen such as are met in 
rachitis, heart disease, syphilis, chronic gastro-enteritis, icterus, vari- 
cella, examination of the blood may not be necessary. 

Splenic and Kidney Tumors. — In rare cases in which sarcoma of 
the left kidney is suspected, it may be necessary to exclude tumor 
of the spleen. 

An enlarged spleen is smooth on the surface and has a sharp an- 
terior edge interrupted by an indentation — the hilus. The tumor is 
pointed and sharp below. It can be grasped deep in the lumbar re- 
gion behind. 

Kidney tumors are irregular on the surface and marked out into 
lobes, some of which may be cystic. The tumor projects upward 
behind into the lower part of the chest. The whole lumbar region 
is flat on percussion. The borders of the tumor are rounded. On 
the other hand, I have made an autopsy in a case of cirrhosis of the 
liver and spleen in which the latter organ during life showed uneven 
tumors on its surface (gummata). 

The physician must be partly guided by the history of a case. 
The urine should be examined in cases of sarcoma of the kidney, 
and the blood in cases of enlarged spleen. I have seen a subphrenic 
abscess displace the spleen downward. The left lobe of the liver was 
also displaced in the same direction. Under anaesthesia, a round 
mass could be felt above the spleen, which was enlarged. Behind, 
the lung came well down to the bottom of the chest, as was evinced 
by the presence of the respiratory murmur. Dulness was, however, 
present in the left axillary line and behind. On exploratory puncture 
in the posterior axillary line, the subphrenic abscess was found to be 
present. 

DISEASES OF THE BLOOD. 

Leading General Characteristics of the Blood in Infancy and 
Childhood. — For diagnostic purposes, it is important to bear in mind 
certain characteristics of the blood in infancy and childhood. 
Ehrlich has shown that conditions normal to the blood in early life 
are of grave import if found in the adult. 

The Red Blood-cells or Erythrocytes. — During the first three days of 
life, nucleated red blood-cells are found in the normal blood. In 
the newly born infant, the red blood-cells number from 4,500,000 
to 6,500,000 to the cubic millimetre (Hayem). There is a polycy- 
themia. This condition is found during the first few days of life. 
On the fourteenth day there is an average of 5,500,000 red blood- 
cells to the cubic millimetre. From the second to the tenth year 
the average number is 5,000,000 (Otto, Schiff, Sorenson). The 
polycythemia in the newly born infant is greater if the tying of 



DISEASES OF TEE BLOOD. 735 

the umbilical cord is delayed until its pulsations cease. Weaklings 
show a diminished number of red blood-cells. In addition to imper- 
fect nutrition, anaemia of any kind, acute or chronic cachexia, and 
certain drugs, such as antipyrin, antifebrin, phenacetin, and lacto- 
phenin, reduce the number of red blood-cells by disintegrating a 
certain proportion of them (Monti). Infectious diseases, such as 
malaria, scarlet fever, typhoid fever, and sepsis, have a similar 
influence. In severe anaemia, such as that accompanying rachitis, 
nucleated red blood-cells appear in the blood. These are also found 
in the severe primary anaemias, in acute leukaemia, and in pernicious 
anaemia of infants and children. 

The White Blood-cells or Leucocytes. — The number of leucocytes in 
the newly born infant is high, being from 18,000 to 30,000 to the 
cubic millimetre (Hayem, Guppen). It gradually falls to 12,000 to 
the cubic millimetre, the average for infants. The percentage of 
lymphocytes is at first small in comparison with that of the poly- 
nuclear leucocytes. Gundobin, whose work has been confirmed by 
Carstanjen, found that the polynu clear leucocytes preponderate in 
the newborn infant. They increase and reach their highest figure in 
the first forty-eight hours of life. They then diminish in number, 
while the mononuclear lymphocytes increase proportionately until the 
seventh or tenth day, when the blood assumes the characteristics 
which distinguish it during the period of infancy. During infancy 
the mononuclear lymphocytes are more numerous than the polymor- 
phonuclear leucocytes. The following table is taken from Gundobin' s 
figures : 

Polymorphonuclear Mononuclear Transitional 

leucocytes. lymphocytes. forms. 

Immediately after birth ... 63 per cent. 25 per cent. 12 per cent. 

Forty-eight hours after birth . 70 per cent. 21 per cent. 19 per cent. 

Infancy 34.6 per cent. 59 per cent. 6.4 per cent. 

In normal infants and young children, the number of leucocytes 
to the cubic millimetre may vary from 13,000 to 20,000 (Japha). 
The so-called digestive leucocytosis found in the adult is inconstant 
in infants and young children (Japha). There is an inflammatory 
leucocytosis in infants and children similar to that seen in the adult. 
It occurs in pneumonia, scarlet fever, rheumatism, sepsis, diphtheria, 
post-hemorrhagic anaemia, and cachexia (sarcoma). In the normal 
state, the leucocytes may reach a minimum of G000 to the cubic milli- 
metre (Monti). This fact should be borne in mind in estimating tin 
leucopoenia in typhoid fever, malaria, tuberculosis, and in other infec- 
tious or toxic states. 

The transitional forms of leucocytes arc numerous in the newly 
born infant, reaching their maximum from the sixth to the ninth 
day. The eosinophiles are present in the same number as in later 
life (Japha). 



736 LYMPH-NODES, DUCTLESS GLANDS AND BLOOD. 

The Haemoglobin. — The blood is richer in haemoglobin at birth 
than later in life (Morse, Leichtenstern, Eotch). After birth the 
percentage of haemoglobin sinks, and at the third month reaches that 
of later life. Carstanjen found the haemoglobin on the average 100 
per cent, np to the twelfth day. The lowest percentages are fonnd 
from the sixth month to the second year. There is, in exceptional 
cases in normal children, a very high percentage from the fifth to the 
tenth year, ranging from 95 to 110 (Widowitz, Leichtenstern, Hock, 
and Schlessinger). The percentage in healthy children may be as 
low as 60 (Fleischl) or 8.4 grammes to 100 c.c. of blood. At the 
third month of infancy it may range from 69 to 94; up to the second 
year it may range from 62 to 81 (Monti). There seems to be no 
fixed normal limit. Anaemia or toxaemia of any kind and infections 
diseases diminish the haemoglobin. 

The Specific Gravity. — The exact clinical significance of the spe- 
cific gravity of the blood is little understood. The specific gravity 
is high in the newly born infant, ranging from 1.056 to 1.066. From 
the sixth month to the tenth year it varies from 1.050 to 1.056 
(Monti). These figures correspond to those of Hock, Schlessinger, 
Lloyd, Jones, and others. The blood of strong children and breast-fed 
infants has a higher specific gravity. Diarrhoea may raise it, but 
rarely to a ratio of more than 0.004 part per 1000. The specific 
gravity is increased in the infectious diseases, pneumonia, pleuritis, 
endocarditis, typhoid fever, and tuberculous meningitis, and falls on 
the decline of these processes. It is also increased in congenital heart 
disease, chorea with endocarditis, icterus, and diphtheria. It dim- 
inishes with the loss in weight accompanying anaemia and nephritis, 
and in cachexia (Hock, Schlessinger, Monti, Hammersley, and 
Felsenthal). 

Anaemia.- — Anaemia is a condition resulting from a deficiency in 
the blood of one or more of its constituent elements. It may be either 
congenital or acquired. In the latter case it may either be secondary 
to other conditions or occur as a primary disease. Congenital anaemia 
is seen at birth in infants born of badly nourished mothers, who dur- 
ing pregnancy have suffered from some disease of the placenta, or 
from syphilis, tuberculosis, or malaria. The foetus in utero becomes 
anaemic. Acquired anaemia appears after birth. It is either sec- 
ondary to some acute loss of blood (post-hemorrhagic), to chronic loss 
of blood, or is caused by defective nutrition, unhygienic surroundings, 
diseases of the various organs, toxaemia, infectious diseases, or 
parasites. 

Primary or essential anaemia is the form in which the changes in 
the blood play so important a role that it is assumed there is a dis- 
ease of the blood itself or of the blood-forming organs. Such are the 
forms of leukaemia, chlorosis, and pernicious anaemia. 



DISEASES OF THE BLOOD. 737 

Simple Anaemia {Secondary Anosmia). — 'Etiology. — Secondary 
simple anaemia may follow some acute or chronic loss of blood. In 
acute post-hemorrhagic anaemia, the increase of fluid elements keeps 
pace with the loss of blood if the loss, though small, is repeated at 
short intervals. Children show the effects of loss of blood much more 
quickly than adults. Hydraemia is the condition which results when 
the loss is marked. The fluid elements increase, and there is a 
diminution in the specific gravity of the blood and in the amount of 
haemoglobin. Hydraemia may result in children without hemorrhage ; 
that is to say, it may occur in extreme severe anaemia secondary to 
some disturbance of nutrition or to illness. In post-hemorrhagic 
anaemia the coagulability of the blood is increased immediately after 
the hemorrhage. Ehrlich supposes this to be due to an increase in the 
number of blood-plates. After the hemorrhage, the regeneration of 
blood in the infant, as in the adult, is indicated by the formation or 
appearance in the blood of microcytes, megalocytes, and nucleated 
red blood-cells (normoblasts). The severe forms of this variety of 
anaemia also show polychromatophilic properties of the red blood-cells. 
These are so poor in haemoglobin that with various stains the normal 
reaction is very much changed. There are various shades of the 
stained red blood-cells. In recent and severe cases of post-hemorrha- 
gic anaemia there may be leucocytosis. There is an increase of the 
polynuclear neutrophilic leucocytes (Monti, Ehrlich). Nucleated 
red blood-cells (normoblasts) may appear in severe cases. Poikilocy- 
tosis is also one of the changes seen in the blood. 

Secondary anaemia of a mild or of a severe type is also seen in 
infants and children who suffer from defective nutrition. It com- 
plicates or accompanies rachitis, syphilis, scrofula, tuberculosis, 
gastro-intestinal catarrh, chronic endocarditis, purpura, morbus 
Werlhofii, and infectious diseases. 

Symptoms. — The symptoms of mild anaemia in infants and chil- 
dren do not differ materially from those of adults. The patient is 
pale and the mucous membranes have a characteristic pallor. The 
appetite is capricious. The patients also suffer from symptoms due 
to the primary affection — syphilis, rachitis, acute infectious disease. 
gastro-enteric disturbance (acute or chronic), or cardiac affection. 
The pallor of cardiac disease or nephritis is characteristic in infants 
and children, as in the adult. 

The anaemia if of a severe type takes the hydremic form. In 
the severe forms of anaemia, especially in infants and very young 
children who suffer from syphilis or rachitis, the skin is waxy or yel- 
lowish white. The ears are absolutely devoid o\' any color of blood. 
In cretinism the skin has a greenish-yello'W line. In hints do not 
show the symptoms, such as dyspnoea or palpitation, seen in older 

47 



738 LYMFB-NODES, DUCTLESS GLANDS AND BLOOD. 

children on exertion. The muscles are flabby and there is a disposi- 
tion to lie quietly in the crib. The spleen may be large, and the liver 
also, especially if rachitis or syphilis is present. In cases in which 
the anaemia is extreme, the spleen may be normal. 

Infants and very % y5ting 'children do not always show the anaemic 
murmurs which are heard over the heart area in older children. In 
older children murmurs of that variety may be present with a venous 
hum in the neck, and the symptoms of mild' and severe anaemia are 
essentially those of later life. These are indisposition to exertion, 
feelings of weakness, drowsiness, lack of appetite, irritability, and 
restlessness. Some of the severe forms of anaemia show for weeks a 
very slight irregular febrile curve. In many cases the fever is due 
to intestinal toxaemia. % \ 

The Blood. — The mild forms of simple anaemia may show only 
a diminution in the amount of haemoglobin, a very slight diminution 
in the number of red cells, a reduction of the specific gravity, and if 
there is a primary affection which, like pneumonia, causes an increase 
in the number of leucocytes, leucocytosis. My records of severe 
forms of anaemia in infants and young children show a diminution 
in the amount of haemoglobin (18 per cent.). The blood shows 
microcytes, megalocytes, megaloblasts, and normoblasts. Increase 
of mononuclear lymphocytes is proportionate to that of the poly- 
nuclear leucocytes. Poikilocytosis in various forms is present, as are 
also polychromatophilic phenomena. In the severe forms of anaemia 
due to malarial poisoning I found, in addition to the plasmodium, 
microcytes, megalocytes, and megaloblasts. The eosinophiles are not 
increased. In severe anaemia, the physical characteristics of the 
blood are striking. It may be so thin as to seperate on puncture into 
a reddish and a colorless portion resembling beef-water. 

Chlorosis. — Chlorosis is a form of primary anaemia. It is not a 
disease of infancy or childhood, and is mentioned here only in order 
to complete the classification of diseases of the blood. Its etiology 
is obscure. Virchow believed it to be due to congenital narrowness of 
the whole arterial system and smallness of the heart. This theory 
does not explain the cases in which recovery takes place. Meinert 
ascribed the condition to an irritation of the abdominal sympathetic. 
Hofman thought that developmental conditions of the genital ap- 
paratus were causal in chlorosis. Forcheimer contends that intestinal 
auto-infection is etiological in producing the chlorotic state, since 
there is in chlorosis an interference with the production of haemo- 
globin, the principal source of which is the gut. 

Occurrence. — Chlorosis is more common in females than in males, 
and occurs at the time of puberty. 

The condition of the blood has been described bv Monti. The 



DISEASES OF THE BLOOD. 



739 



haemoglobin is diminished. The number of red blood-cells is in mild 

cases scarcely at all reduced. In severe cases it may fall to 1,000,000 
to the cubic millimetre. The absolute amount of haemoglobin may 
reach 4 to 8 in 100 cubic millimetres of blood. The specific weight 
may be reduced to 1035. There are microcytes in the blood. There 



Fig. 170. 




rsoudoleuka-inu' ; 



alarged spleen and liver. 



is no lcueocytosis. There are poikilocytosis and polychromatophilic 
appearances in the stained blood, 

Pseudoleukaemic Anaemia of von Jaksch {Anosmia Infantum 
Pseudol&ukcBmica.) — In 1889 von Jaksch described a symptom-com- 
plex met with among infants and young children, to which he gave 



740 LYMPH-NODES, DUCTLESS GLANDS AND BLOOD. 

the name of anaemia infantum pseudoleukemia. He described the 
condition as a clinical entity which, in running its course, gives the 
picture of severe lymphatic anaemia. There are enormous enlarge- 
ment of the spleen, slight enlargement of the liver, some enlargement 
of the lymph-nodes, and changes in the blood. It is a secondary 
anaemia rather than a distinct disease. For this reason Fischl, 
Epstein, and others deny that it is a clinical entity. On the other 
hand, Monti and Luzet have described numbers of cases. I have 
records of 9 cases, which were published. The anaemia is extreme. 

Etiology. — It is difficult to determine the etiology. Yon Jaksch 
and Monti trace an intimate connection between this condition and 
rachitis. Wentworth and the Italian school regard it as secondary to 
some form of intestinal infection. 

Occurrence. — The condition is rarely found before the age of 
six months. My cases ranged from the ages of eleven to twenty 
months. It may occur up to the third year, and is most common from 
the seventh to the twelfth month. Most of the cases thus far pub- 
lished have occurred in infants or children suffering from rachitis or 
congenital syphilis. In all of my cases there were signs of rachitis. 
Some of the children had previously suffered from chronic gastro- 
enteric derangement. 

Morbid Anatomy. — The post-mortem findings published by von 
Jaksch, Luzet, Baginsky, Holt, Glockner, Lehndorf, and the writer 
correspond very closely. 

The spleen was large and firm, the liver hard and enlarged, and 
the mesenteric lymph-nodes were enlarged. A histological exami- 
nation revealed the bone-marrow rich in cells; there were normo- 
blasts, leukocytes with granules and those without granules; there 
were myelocytes, eosinophiles, and giant cells, also cells containing 
pigment. The marrow was a richly cellular mixed marrow. The 
liver cells were normal; there were nucleated red blood cells in the 
capillaries, and myelocytes. The kidney showed parenchymatous 
degeneration, the heart was negative, the lungs showed peribronchitic 
infiltration, the spleen showed increased connective tissue, pulp rich 
in cells, capillaries dilated, eosinophiles present in moderate numbers, 
nothing abnormal found. Lehndorf was inclined, from the appear- 
ances, to regard the anatomical diagnosis of myelemia, especially 
supported by the appearances found in the liver, and kidney, although 
the spleen and lymph-nodes were less affected, and there was no 
siderosis. It will be shown later on how little justified this conclusion 
was. 

Symptoms. — The infants affected have as a rule suffered from 
chronic intestinal disturbances. Most of them are bottle-fed and 
atrophic. Although the skin is intensely anaemic and of a yellow, 



DISEASES OE THE BLOOD. 741 

waxy tinge, there is sometimes a panniculus of fat. The musculature 
is flabby and the abdomen large. As a rule there are signs of rachitis. 
The fontanelle is open and the eruption of the teeth delayed. The 
infants are irritable, peevish, do not willingly take food, and do not 
assimilate it. In one of my cases, there was complicating pneumonia. 

There is, as a rule, no fever, unless it is due to intestinal toxaemia. 
The picture is one of progressive emaciation and anaemia. In some 
cases there is complicating icterus, and the spleen reaches to the crest 
of the ileum. The edge of the spleen is sharp and the hilus can be 
distinctly felt. The liver is slightly enlarged; its edge is round and 
smooth. In one of my cases, it extended two and one-half inches 
below the free border of the ribs (Fig. 170). The lymph-nodes in 
the groin and axillae are slightly enlarged, sometimes only to the 
size of a bean. 

The Blood. — The specific gravity of the blood is reduced. The 
haemoglobin may be reduced to one-quarter the normal percentage. 
It may be as low as 17 per cent. There is a marked diminution of 
the number of red blood-cells. The nucleated forms of erythrocytes 
are abundant. There are megaloblasts, which show karyokinesis. 
In addition there are red blood-cells of all sizes — microcytes and 
megalocytes. There is poikilocytosis to a marked degree, and also 
polychromatophilia. The leucocytes are only moderately increased. 
In the severe cases the proportion of white blood-cells to the red may 
be as 1:100, 1:80, or 1:15 (Monti). The picture given by the 
leucocytes is different from that of leukaemia. Most authors agree 
that the various forms are represented and increased in equal ratio. 

In my nine cases the blood-picture was as follows : The hemo- 
globin ranged from 28 to 65 per cent. ; the count of red blood-cells 
or erythrocytes fell as low as 1,400,000 and in others was as high as 
4,448,000 ; and the leucocytes ranged from 5,200 to 7,500 to 40,000 
and 80,000 to the cubic millimeter. In all cases there were nucleated 
red blood-cells, normoblasts, and megaloblasts from 7 to 15 per cent. 
In some cases the white cells varied from 11,000 to 80,000 to the 
cubic millimeter in a given case, with erythrocyte count of 2. GOO. 000 
to 3,700,000. 

Some writers think there is a predominance of polynuclear leuco- 
cytes, but this is scarcely so, as in some cases they comprised 80 per 
cent, of the white blood cells, while in others they fell as low as 11 to 
15 per cent. This may occur in the same case in which blood-counts 
have been taken a few days apart. A leukocytosis or a polynuclear 
leucocytosis, therefore, is of no diagnostic import. 

The myelocytes were present in all cases, varying in frequency 
from \ per cent, lo 7 per cent. In some cases at different times the 
myelocytes varied from .1 per cent, to l.l per cent, in different counts. 



742 LYMPH-NODES, DUCTLESS GLANDS AND BLOOD. 

It has been shown elsewhere that the myelocytes, also, are not of 
specific value as differentiating these cases from other cases of severe 
anaemia, and the variation in the same case, at different times of the 
percentage of these cells, would tend to confirm this view. 

The eosinophils were present in normal percentages in all the 
cases. 

Mast cells were present in all cases in percentages varying from 
1 per cent, to 4 per cent. 

A study of the blood pictures in my uncomplicated cases only 
tends to confirm the belief expressed by others that the blood picture 
in this disease is not a definite pathological picture of anything but a 
severe anaemia in children in whom any disturbances of the functions 
of the blood-forming organs causes a retrograde to the foetal structure. 

A comparison of the above blood pictures with those published 
by Lehndorf, Fowler, Monti and Berggriin, Zelenski and Cybulski 
show a remarkable correspondence, and prove my contention that 
though the blood picture is not specific, the clinical features of these 
cases are characteristic, inasmuch as so many observers agree as to 
the physical, clinical signs. 

Diagnosis and Course. — The clinical picture presented by cases of 
anaemia, described by Von Jaksch, and following him by writers 
mentioned, is certainly easy of recognition. 

The anaemic habitus, the tumored abdomen, the spleen of enor- 
mous size, the increased size of the liver, the intestinal disturbances, 
easily enable us to recognize such cases apart from the cases of 
slight anaemia, with moderate enlargement of the spleen. There is 
nothing, however, in these cases which suggests leukaemia, except it be 
the large liver and spleen. The course of some of these cases result- 
ing in complete and satisfactory recovery, certainly impresses me 
with the fact that the condition is rather one of a severe disturbance 
of the nutritive functions of certain organs, such as the intestine, and 
its large secretive glandular system, reacting upon certain organs, 
such as the spleen, causing changes in the same, with secondary 
changes in the blood, which may assume a role of primary impor- 
tance. 

Von Jaksch's anaemia is, therefore, a severe secondary anaemia, 
with or without marked leucocytosis. Those cases which have been 
reported as terminating in true leukaemia were really cases of leukae- 
mia from the outset. Cases of true Von Jaksch disease, if they 
terminate fatally, do so from some intercurrent disease, such as 
pneumonia or tuberculosis, to which they fall easy victims. 

Treatment. — Thus far the treatment has been empirical. Small 
doses of Fowler's solution are indicated. If rachitis is present, 
phosphorus is given by some in small doses. I have seen cases do 



DISEASES OF THE BLOOD. 743 

badly under that treatment. Tonics and an easily assimilable diet 
are indicated. The bowels should be kept clear by enemata given 
daily in order to lessen the possibility of infection of the gut. 

Leukaemia (Leukocythaemia). — Leukaemia is a persistent condi- 
tion of the blood in which there is an increase of the white blood- 
cells, and a diminution of the red ones. It is a primary disease of 
the blood itself. Accompanying it are changes in the spleen, liver, 
bone-marrow, lymph-nodes, and lymphoid tissues. Virchow called 
the condition " white blood." French writers have called it leukocy- 
thaemia. The proportion between the white and the red blood-cells 
is not so distinguishing a feature as the appearance of large numbers 
of lymphocytes in the blood, in which they are normally present in 
only small numbers. In one form the appearance of mononuclear 
neutrophile-staining myelocytes which are normally absent is a dis- 
tinguishing feature. Ehrlich characterizes leukaemia as a mixed 
leucocytosis of chronic course, since white blood-cells of all kinds are 
present in the blood. This is not the case in the polynuclear and 
eosinophile leucocytosis. 

Occurrence. — The disease is rare in childhood, but some authors 
believe it to be more common in the first year of life than is generally 
supposed (Monti, Mosler). Fifteen to 20 per cent, of the cases occur 
in the first decade of life (Baginsky). Males are more frequently 
affected than females. The disease is believed to be hereditary. 

Etiology. — The etiology of the affection is still unknown. In a 
few cases, micro-organisms and sporozoa have been found in the blood 
(Roux, Kelsch, Veillard, Lowit). The sporozoa of Lowit are de- 
scribed by him as being free in the blood as well as in the leucocytes 
and in the blood-making organs. In lymphatic leukaemia they are 
described as being intracellular only. Auer has described intracellu- 
lar bodies in the leucocytes resembling capsulated bacteria. 

Some writers think that rachitis and syphilis predispose to the 
development of leukaemia, especially if the bones are involved as well 
as the liver, spleen, and lymph-nodes. Certain forms of anaemia fol- 
lowing malaria, diphtheria, and scarlet fever, and accompanied by 
enlargement of the liver, spleen, and lymph-nodes, may, according 
to some writers, pave the way for leukaemia. Physical or mental 
strain, unhygienic living, defective nutrition, and traumatism of the 
spleen, have all been regarded as predisposing factors. 

Forms. — The simplest classification of leukaemia is that based 
upon the anatomical appearances of the blood. Such is the classifica- 
tion of Ehrlich, which is as follows : 

(a) Lymphatic leukaemia, in which there is a marked hyper- 
plasia of lymphoid tissue. 

(b) Myelogenous leukaemia, in which there is hyperplasia of 



744 LYMPH-NODES, DUCTLESS GLANDS AND BLOOD. 

myelogenous tissue. Lymphatic leukaemia may run an acute or a 
chronic course. In both forms the distinguishing feature is the 
appearance in the blood of large numbers of the mononuclear lym- 
phocytes and the displacement of the polynuclear leucocytes. The 
acute form is rare. It occurs in childhood. Eight cases have oc- 
curred in my hospital service in the past six years. Its course is 
rapid. There are slight or marked tumor of the spleen, slight or very 
marked enlargement of the liver, and a tendency to petechia and to 
general hemorrhages. Some authors regard these cases as infectious. 
The chronic forms show marked enlargement of the spleen. 

Changes in the Blood. — As was previously stated, the lymphatic 
forms of leukaemia are distinguished by the appearance, in the blood, 
of large numbers of the small and large mononuclear lymphocytes. 
In the myelogenous forms, a cell which is normally not present in the 
blood, but is indigenous to the bone-marrow, appears in large num- 
bers. This cell is the large mononuclear neutrophilic staining cell, 
the myelocyte of Ehrlich. The mast-cells are also found in these 
cases, but are not peculiar to this form of anaemia. In addition there 
is in the myelogenous forms of leukaemia an increase in the number 
of all three types of granulated white cells, the neutrophiles, the 
eosinophiles, and the mast-cells. There are dwarf forms of the white 
blood-cells, mitoses, and lastly large numbers of nucleated red blood- 
cells. Normoblasts, megaloblasts, and myelocytes are not normally 
present in the blood. They are occasionally found in penumonia, 
and in leucocytosis. The eosinophiles are increased to fifteen times 
their normal number. The slow coagulability of leukaemic blood is 
characteristic. 

The spleen is enlarged. It is at first soft, often firm, and is 
infiltrated with lymph-cells. The capsule is thickened ; the connec- 
tive-tissue stroma is increased and infiltrated with lymph-cells. The 
lymph-nodes show similar changes, and may be enlarged, forming 
tumors of considerable size. 

The bone-marrow is so infiltrated with lymph-cells as to acquire 
the appearance of a purulent infiltration. The same lymphoid infil- 
tration is found in the liver. The follicles of the gut are swollen. 
There is an increase of lymphoid cells and tissues. The lymphoid 
tissues elsewhere, such as the tonsils, thymus, skin, and even the 
retina, show the same changes. There are hemorrhages and exudate 
in the ear, and the nerves and nervous tissue of the central nervous 
system are the seat of lymphoid cellular invasion. 

Symptoms. — The Acute Form. — Cases of acute leukaemia in 
infancy and childhood have lately been increasing in the literature. 
The most recent cases include those of McCrae, in a boy aged three 
years, and of Miller, in an infant of eight months. Cases have also 



DISEASES OF THE BLOOD. 



74 



been reported by Morse, Japha, Strauss, Monti, Berggriin. The most 
frequent is the lymphatic form. The symptoms in all the published 
cases were similar. In a boy eight years old, admitted to my hospital 
service, there were no premonitory symptoms. Two months before 
admission he was in good health. He became very pale, there were 
irritability and loss of appetite, and the abdomen increased markedly 
in size. He complained of pains in the legs, and at the onset had 
chills and fever every other day. After the appearance of the chills 



Fig. 171. 




Acute lymphatic leukaemia. 



Enlarged lymph-nodes, spleen, and liver, 
one-half years of age. 



Boy four and 



he suffered from a low irregular fever. A week before death, the 
skin had a waxy color, there were petechia* on the extremities, the 
gums bled easily, and the lymph-nodes of the axillse and groin were 
enlarged. There was an anamie murmur with the first sound of the 
heart; the liver was enlarged below the free border of the ribs to the 
extent of two fingers' breadth; the spleen was enlarged to the level of 
the umbilicus; the fundus of the eve showed retinal hemorrhages. 
Examination of the blood showed the hsemofflobin to be reduced to 15 



746 LYMPH-NODES, DUCTLESS GLANDS AND BLOOD. 






per cent. (Fleischl). The red blood-cells numbered 1,012,000 to the 
cubic millimetre; the white blood-cells, 37,000. There was an im- 
mense preponderance of lymphocytes (mononuclear). The patient 
died with signs of progressive weakness. Coma was preceded by 
vomiting and the appearance of a few petechia?. The blood state 
continued much the same as at first. In another case the number of 
mononuclear lymphocytes was fully 75 per cent, of the white blood- 
cells. 

In both these cases the spleen and liver diminished in size before 
death. The proportion of white to red blood-cells may not be far 
from normal. In another case the nucleated red blood-cells, large and 
small, were very numerous. In this case, in a boy of four and one-half 
years, the nodes around the parotid and angle of the jaw, in the 
axilla, and in the inguinal region, increased in a short time to a large 
size, and the spleen grew rapidly larger and reached to the crest of 
the ilium. The liver reached to the umbilicus. These mediastinal 
lymph-nodes were enlarged and caused great dyspnoea. The distress 
way very great just before the lethal issue (Fig. 171). In a case of 
v. IsToorden's the proportion of the white to the red blood-cells was 
1 : 200. The predominance of the lymphocytes is diagnostic. Most 
of the cases published showed a slight temperature. The fatal issue 
usually results a few weeks or a month or two after the onset of 
symptoms. 

The Chronic Form. — The symptoms of the chronic form extend 
over a greater length of time. For months there are anaemia, lassi- 
tude, and extreme physical weakness. The appetite is good, but in 
spite of abundant nourishment, emaciation is progressive. In some 
cases there are periodic diarrhoeal attacks. Profuse hemorrhage may 
occur without warning either from the nose or intestines. Chills and 
fever resembling those of paludism are sometimes present. None of 
these symptoms is particularly characteristic. 

As the disease progresses there are headache and pain in the limbs 
and in the region of the spleen. The anaemia after a time assumes a 
severe type, and the skin becomes waxy and yellow. At this stage 
the spleen and liver enlarge and distend the abdomen. There are 
dyspnoea and palpitation; the anaemia takes the hydrsemic form, and 
there is oedema of the face, hands, and feet. Hemorrhages then occur 
from the nose, lungs, mouth, intestines, but rarely from the kidneys. 
There are petechia? in the skin and hemorrhages in the retina. 

In the lymphatic form the lymph-nodes in various parts of the 
body enlarge and form masses which are painless and covered with 
unaffected skin. The skin may be affected by the process. The 
mesenteric nodes may sometimes be felt through the abdomen. The 
spleen attains an enormous size. The liver may extend as far as the 



PLATE XXXIII 




Hodgkin's Disease in a Child. 



DISEASES OF THE BLOOD. 741 

umbilicus. Respiratory difficulties, heart weakness, and nervous 
symptoms (such as vertigo, somnolence, and coma) end the clinical 
course of the disease. The urine is diminished, and contains hyaline 
casts, lymphoid cells, and a trace of albumin. There may be a slight 
continued fever in the course of the disease. 

Prognosis. — The prognosis is unfavorable. Of 39 cases collected 
by Birch-ITirschfeld, only 4 recovered. Only in the early stage is 
recovery possible. Death supervenes from exhaustion with hemor- 
rhages or from intercurrent pleuritis or pericarditis. 

Treatment. — The treatment of a disease whose exact nature is still 
unknown is difficult. Good food, and hygienic surroundings are the 
first requisite. In the treatment of anaemia, the iodide of iron, cod- 
liver oil, and arsenic are the chief drugs employed. In the lymphatic 
form, arsenic in the form of Fowler's solution gives the best results. 

Hodgkins' Disease (Ancemia Lymphatica; Adenie; Pseudoleu- 
kemia; Lymphadenoma) .—This disease is really not an affection of 
infancy and childhood inasmuch as 75 per cent, of the cases occur 
above the age of ten years. It is mentioned here to emphasize its 
characteristics as distinct from tuberculous adenitis or scrofulous 
enlargements of the lymph-nodes. It is an affection beginning with 
the enlargement of the lymph-nodes of the neck, usually of one side, 
and accompanied by an enlarged spleen and liver. In the spleen, 
liver, and other organs there are nodular growths. There is a pro- 
gressive cachexia accompanied by febrile periods. The disease is 
fatal either in a short time of a few months or after a period of two 
or three years, during which there may be intervals of improvement. 
There are no changes in the blood such as are seen in true leukaemia, 
and in this lies the main element of differential diagnosis. A most 
complete account of the nature of this rare affection will be found in a 
recent monograph by Dr. Keed, published in the Johns Hopkins 
Hospital Reports, Vol. X., and in a monograph by Clarke in which 
he collected 43 cases. 

The Hemorrhagic Diatheses. — In this class of diseases are em- 
braced only those affections which are due to some primary change in 
the blood or in the circulatory apparatus. Thus conditions which are 
due to local disease of some organ, or the hemorrhages which follow 
the acute infectious diseases or drug poisoning are not included. 
Kxperimental pathology has as yet not given any clue to the etiology 
of the hemorrhagic diatheses. The contention of William Koch and 
Ajello, that they are infectious diseases or are due to some auto- 
intoxication, is not universally accepted. At present the clinical 
classification of these diatheses into the transitory forms in which are 
included purpura simplex, poliosis rhemnatiea luvmorrhagica, scorbu- 
tus, and (lie persistent form hereditary iii character, such as hsemo- 



748 LYMPH-NODES, DUCTLESS GLANDS AND BLOOD. 

philia, may be accepted. In the latter, the hemorrhage may be exten- 
sive, difficult to control, and due to some very slight cause. 

Simple Purpura. — This is a transitory condition characterized by 
small hemorrhages or petechia?, or large, irregularly shaped extrav- 
asations of blood. These are as a rule discrete, but may be confluent, 
and are situated in the epidermis or in the superficial layers of the 
cutis. Immediately after the extravasation the hemorrhages have a 
bluish-purple tinge. After a few days they become brown or green- 
ish-yellow. These extravasations are seen most frequently on the 
lower extremities, generally on the extensor surface. They also occur 
in other localities. 

As a rule there are few or no symptoms. There may be crops of 
petechia? appearing at short intervals. In a few cases there are, after 
an exacerbation of the local phenomena, loss of appetite, vomiting, 
and general malaise. The so-called purpura cachecticorum appears 
on the body, abdomen, back, and upper extremities in children under 
two years, suffering from diarrhoea and other exhausting diseases. 
In the latter case there may be leucocytosis, due to the original affec- 
tion. The changes in the blood in simple purpura are still to be 
studied. 

Etiology. — The cause of this purpura is still unknown. It may 
be due to some obscure toxaemia. 

Prognosis. — The prognosis is very good in the primary form. In 
the secondary form it will depend on the nature of the original affec- 
tion. 

Treatment. — The treatment will depend on the nature of the origi- 
nal disease. I treat the purpura itself in the same manner as cases 
of purpura hemorrhagica, which will later be fully described. 

Haemophilia. — Haemophilia is a rare condition of the blood and 
blood tissues which may be congenital or hereditary. It becomes 
apparent at birth or in early infancy, and is rare in later life. 

Nature. — The nature of the affection is obscure. It is a type of 
hemorrhagic diathesis which is transmitted from generation to gene- 
ration in the female line. It is characterized by the occurrence of 
uncontrollable hemorrhage after very slight injuries, and operations, 
and also in the absence of known traumatism. 

Etiology. — Many theories of the cause of the affection have been 
advanced. They may be grouped as follows : 

(a) An abnormal delicacy and friability of the bloodvessels. 

(&) An increase of the volume of blood (Immerman). 

(c) A defect in the coagulable constituents of the blood. 

(d) Certain agencies acting as toxins on the elements of the 
blood, causing their dissolution (Koch). 

The condition is most common in the Slavic races. Children 



PLATE XXXIV 




Haemophilia. Boy six years of age. Hsematoma of the face 

hemorrhage into the knee-joint. (Case of Or. Martin Ware. 



DISEASES OE THE BLOOD. 740 

dying of the affection show evidences of intense anaemia, but may be 
well nourished. Virchow has demonstrated that there is a narrow- 
ness in the arteries and also a thinness of their walls. Birch-Hirsch- 
feld found that the endothelium of the arteries was enlarged, and that 
the nuclei were swollen. The blood itself shows no changes except 
those proper to post-hemorrhagic ansemia. 

The hemorrhages may occur in any region and from any organ of 
the body. There may be hemorrhage into joints, profuse epistaxis, 
intestinal hemorrhage or uncontrollable hemorrhage from the mouth 
or lung. The drawing of a tooth, the incision of an abscess, or a 
minor operation such as circumcision, may cause uncontrollable and 
fatal hemorrhage. In the newly born infant, there may be fatal 
hemorrhage from the cord. In the case pictured in Plate XXXIV. 
there were hemorrhages into the joints and into the face, without 
distinct traumatism. This case came of a family of bleeders in which 
there had been fatalities following surgical operations. 

The condition lasts weeks, months, or years — in fact, it persists 
during the life of the individual. Some authors believe that the 
female members of families thus affected should not marry. 

Treatment. — The treatment is mainly prophylactic. The infant 
should nurse a wet-nurse, in order that the noxious influence of its 
own mother's milk may be lessened. Good food and fruits of all 
kinds should be given. All operations and traumatism should be 
carefully avoided. 

Purpura Hemorrhagica (Morbus Maculosus Werlhofii). — In the 
prodromal period before the appearance of the hemorrhages, there 
may be several days of general malaise, disturbance of appetite and 
digestion, and febrile movement. There are ansemia, pain in the 
limbs, and oedema of the feet. The hemorrhages may appear without 
any symptoms. They are especially frequent in the lower extremities. 
and next most frequent in the upper extremities and on the chest, 
face, and trunk. They consist of extravasations of blood in the skin 
and subcutaneous tissue. The mucous membranes are frequently 
affected. 

Epistaxis, bleeding of the gums, bloody movements, and bloody 
urine result. There are ecchymoses in the conjunctiva and bleeding 
from the ear. The hemorrhages in the skin may bo petechiae, or 
irregular bluish or purple blotches which subsequently become yellow- 
ish or greenish yellow. They occur spontaneously or follow slight 
traumatism or pressure. There may be hemorrhages into the joints. 
There may be exacerbations and recurrences o( hemorrhages extend- 
ing over weeks. The tendency of the mucous membrane to Bleed has 
been mentioned. The gums are spongy and bleed easily. There are 
hemorrhages or petechia on the soft and the hard palate. The hemor- 



750 LYMPH-NODES, DUCTLESS GLANDS AND BLOOD. 

rhages from the kidney cause the appearance of albumin and blood in 
the urine. The urine is red and blood-coloring matter may be found 
by the turpentine-guaiac test. Hemorrhages in the brain and central 
nervous system may occur, causing paralyses and coma. In mild 
cases there is no disturbance of nutrition, but in severe ones the 
anaemia is marked, as is also the emaciation. The blood shows few 
changes. The number of red blood-cells is diminished, as is also 
the specific gravity. In severe cases there is a slight leucocytosis ; the 
polynuclear leucocytes are increased, eosinophiles are few, microcytes 
are present, and there are a few normoblasts. The leucocytosis im- 
proves as recovery sets in. 

Etiology. — The etiology of this affection is still obscure. Because 
of its infectious nature, William Koch believes it to be allied to 
scorbutus and other hemorrhagic affections. His view is not sup- 
ported by other writers. Ajello and Schwab regard the condition as 
an auto-infection or a form of toxsemia. Kolb, Tizzoni, and Babes 
have found bacteria in the blood of fatal cases. Others have isolated 
streptococci and staphylococci from the blood (Lebreton). In one 
of my cases there was a history of an insect-bite. The disease is 
rare in breast-fed infants and is more common after than before the 
age of two years. The infants and children attacked may have pre- 
viously been in good health. 

Diagnosis. — The diagnosis is made from the course of the affection 
and the size and nature of the hemorrhages. The constitutional dis- 
turbance is more marked than in simple purpura. The hemorrhages 
are blotchy, in that respect differing from the petechias of peliosis. 
The joints are not swollen,, as in the latter affection. 

Prognosis. — The cases of ordinary severity recover. Severe cases 
may recover or may result fatally. 

Treatment. — The treatment consists in placing the patient in 
hygienic surroundings, and giving a nutritious diet with a liberal 
allowance of fruit and vegetable acids. In marked cases, Fowler's 
solution, given in moderate doses, gives good results. 

Purpura Rheumatica (Peliosis Eheumatica of Schonlein). — Pur- 
pura rheumatica consists of an eruption of small discrete purpuric 
spots in the vicinity of the large joints, especially of the lower extrem- 
ities about the knee. The accompanying symptoms are pain and 
swelling of the joints of the lower or upper extremities. 

Etiology. —The etiology is obscure. The disease occurs in children 
previously healthy. It is seen in older children only, and has no 
apparent relation to acute articular rheumatism. 

Symptoms. — Slight fever is followed by the appearance of the 
purpuric spots and the swelling of the joints of the lower and rarely 
of the upper extremities. The joints are painful, as in rheumatism. 






DISEASES OF TEE BLOOD. 751 

At times the swelling of the joints is less apparent, but there is 
nevertheless tenderness on pressure. The purpuric spots are partic- 
ularly numerous in the vicinity of the joints. A genera] urticaria 
may precede the appearance of the purpura. There arc no heart 
complications. The condition of the blood is not as yet understood. 
There may be several crops of purpuric spots appearing at intervals 
of days or weeks. In other cases there are oedema of the face and 
enlargement of the spleen. In one of my cases there were at first 
slight hemorrhages from the bowel. There may be epigastric pain 
and tenderness in the course of the disease. 

The average duration of the affection is from ten to fourteen day-. 
There may be relapses extending over weeks. 

Prognosis. — The prognosis is good even when there are several 
relapses and when the affection takes a subacute course. 

Treatment. — Rest in bed is the first requisite of treatment. The 
patient is put on a nutritious diet in which there is an abundant 
allowance of fruit and vegetable acids. Lemonade and orange-juice 
are especially indicated. The bowels are regulated and the salicylate 
of sodium is given in moderate doses. A child four years of age is 
given grains v (0.3) three times daily. The pains in the joints are 
easily controlled by rest. In the subacute stage small doses of 
Fowler's solution are of great benefit. 

Henoch's Purpura. — Henoch in 1874 described a series of 4 cases 
of purpura which he classified as distinct from purpura hemorrhagica 
or peliosis rheumatica. The symptoms were as follows: Children 
in apparent good health were attacked by a form of purpura in which 
there were arthritic pain, vomiting, and intense abdominal pains with 
bloody diarrhoea. The rheumatoid pains were accompanied by swell- 
ing of the joints. The purpura was of the hemorrhagic type — that 
is to say, there were extravasations of blood in the form of ecchymoses 
or raised exanthematic areas, not disappearing on pressure. The 
areas were situated on the abdomen and lower extremities. The 
joints affected were those of the wrist, elbow, and ankle. The intesti- 
nal symptoms consisted of repeated vomiting, tympanites, excruciat- 
ing colicky pains, bloody stools, and tenesmus. One case was fatal. 
Such cases have been from time to time described by other observers. 
I have seen a number of cases. 

These cases are at present regarded as due to a form of intestinal 
infection the exact nature of which is still obscure. They constitute 
a group probably belonging to the class of primary hemorrhagic affec- 
tions in which is included the so-called poliosis rheumatica. 

Diagnosis of Forms of Purpura. — It is not always possible, clinically, 
to assign each form o( purpura \o its proper class. This is especially 
true with young children, in whom there occur forms oi purpura 



752 LYMPH-NODES, DUCTLESS GLANDS AND BLOOD. 

showing a diversity of symptoms and not fitting into any sharply 
defined class. Nor is it always possible at the bedside to decide 
whether the condition present is scorbutus or idiopathic purpura. 
Characteristic of both purpura and scorbutus are the hemorrhages 
into the skin, the internal organs, the serous cavities, and the mucous 
membranes. On the other hand, the frequency of hemorrhages and 
affections of the gums, the prodromal cachexia, the joint-affections, 
and the periosteal hemorrhages are peculiarly characteristic of that 
form of scurvy called Barlow's disease^ which is seen in nurslings and 
young children. The purpuric affections of so-called idiopathic type, 
in which a purpuric exanthema is spread over the whole surface, may 
be called simple purpura. 

In the so-called rheumatic purpura or peliosis rheumatica there 
is a blotchy hemorrhagic exudate over the surface in the vicinity of 
the joints, with pain in the joints, and gastric pains. There is always 
a tendency to relapses. Hemorrhages from the mucous membranes 
and bowels are rare, but occasionally occur. 

In purpura hemorrhagica or morbus Werlhofii there are minute 
or blotchy hemorrhages in the skin and internal hemorrhages from 
the mucous membranes, stomach, and intestines. Attempts to define 
sharply each of these sets of cases have been made. It is not always 
possible or desirable to do so. I have seen cases of peliosis with 
bowel hemorrhages and gastric crises, and cases of purpura hemor- 
rhagica in infants, in which there were pains in the joints, evinced 
by the distress shown when the joints were moved. The forms of 
purpura regarded by Henoch as a distinct type are classed by others 
as purpura rheumatica.- The different classes of idiopathic purpura 
therefore overlap, one case frequently showing symptoms of two types. 
The only possible conclusion is that there may be a common cause 
of all forms of purpura — probably an infection. 

Pernicious Anaemia. — This is a primary anemia which causes 
progressive impoverishment of the blood and results in death. It is 
not common in infancy and childhood. The condition of the blood in 
pernicious anemia in infancy and childhood has not as yet been 
closely studied. The changes in the blood which have been published 
as characteristic of this condition in infancy and childhood are found 
in other states, such as the severe ansemia of rachitis and syphilis. 
Ehrlich is not disposed to accept these cases without question. Blood 
pictures which in the adult may be diagnostic of pernicious anemia 
cannot be thus interpreted when found in infants and young children. 
Observers of note, such as Monti, Berggriin, and Baginsky, have pub- 
lished cases in infants and young children. I have met a case in an 
infant which had been bitten by a rat. After an interval, anaemia 
of a progressive and fatal type set in. The changes in the blood were 



DISEASES OF THE SUPRARENAL BODIES. 753 

similar to those characteristic of the same form of anaemia in the 
adult. Monti has collected 16 cases, 2 of which were in infants; 5 
ranged from one to six years ; 9 were above the age of five years. On 
the other hand, Ehrlich found that of 240 authentic cases, only 1 
occurred in the first decade of life. That case was in a girl of eight 
years. In the face of such great diversity of opinion, it is wise to 
await the results of further research. For the purpose of reference, 
the following account of the changes in the blood which, according to 
Ehrlich, are diagnostic of pernicious anaemia in the adult, is ap- 
pended : 

(a) The volume of blood is markedly diminished. 

(b) The color is at first normal, but later resembles that of beef- 
water. 

(c) The haemoglobin may be as low as 10 per cent. (Fleischl). 
This is due to a diminution of the number of red blood-cells, for the 
individual cell may have a haemoglobin content equal to the normal 
or above it. 

(d) There are microcytes, megalocytes, and sometimes giganto- 
cytes. The megalocytes may constitute 70 per cent, of the red blood- 
cells. They become fewer on convalescence. There are few megalo- 
blasts, but characterise normoblasts are found. 

(e) Clumps of free granules are found in the blood. The red 
blood-cells may contain granules. 

(/) Staining solutions produce polychromatophilic effects. 

(g) The eosinophiles are normal in number. 

(h) The number of white blood-cells is diminished as well as 
that of the polynuclear neutrophiles. The latter condition indicates 
serious involvement of the bone-marrow. The lymphocytes are 
proportionately increased. 

(i) The leucocytes show no changes. Improvement is ushered 
in by leucocytosis. 

(;) The specific gravity of the blood is diminished, as is also its 
coagulability. 

In my case the nucleated red blood-cells were numerous. 

DISEASE OF THE SUPRARENAL BODIES. 

Addison's Disease (Morbus Addisonii). — This is an exceedingly 
rare affection before the tenth year of life. 0( IS eases collected by 
Dezirot, only 6 occurred before the tenth year. Most o\' the eases col- 
lected by this author (in children) occurred before the twelfth and 
fifteenth years, [t may occur in the newborn. It is caused by tuber- 
culous degeneration o( the suprarenal capsule, although in one ease 
there was earinoma of ibis organ. Apart from asthenia and melano- 

48 



754 LYMPH-NODES, DUCTLESS GLANDS AND BLOOD. 

dermie, gastrointestinal disturbances and convulsions dominate the 
development of the disease. Vomiting is very frequent. The con- 
junctiva and nails escape pigmentation. 

The duration is shorter and the disease more rapidly fatal in 
children than in adults. Sudden death is a frequent termination. 
Enlargement of the mesenteric lymph-nodes and Peyer's patches and 
solitary follicles have been observed. The pigmentation of the buccal 
and other mucous membranes remain, as in the adult, pathognomonic 
of the disease. It must be differentiated from tuberculosis of the 
peritoneum with melanodermie and gastro-intestinal crises. Pigmen- 
tation, however, of the mucous membranes remains characteristic of 
Addison's disease. 

Treatment. — Inasmuch as the operative treatment in adults has 
in certain cases caused an amelioration of the symptoms, it might 
also be tried, if the diagnosis is certain, in children. 



SECTION XII. 

DISEASES OF THE BONES. 

General Considerations. — In examining the joints, it should be 
home in mind that the hones entering into the formation of the joints 
may be affected. The diaphysis may he diseased without accompany- 
ing involvement of the joint. 

Tuberculosis. — In all hone lesions tuberculosis should be excluded. 
In infants and children, the question as to whether the existing con- 
dition is tuberculosis of the bone or syphilis is constantly arising. 

Syphilis affects by predilection the long bones in the diaphysis, 
while tubercle affects the short bones, especially in the vicinity of the 
joints. In this region, also, tubercle attacks the epiphyses of the bone 
and may thus involve the joints secondarily. 

Pain in syphilitic bone lesions is very marked, acute, and with 
nocturnal exacerbations ; while the pain of tubercular bone lesions 
is obscure and indefinite, although persistent. 

The swelling in syphilis is in the form of a periostitis or an ostitis: 
involving only the bone ; in tuberculosis, the surrounding tissues are 
affected as well as the bone, and abscess and fungous granulation 
result. 

Syphilis rarely suppurates; the contrary is true of tuberculosis. 

Syphilis of the bones does not as a rule lead to cachexia ; tuber- 
culosis of the bone eventually causes cachexia and emaciation. 

There are cases in which doubt will arise as to the true nature of 
the bone affection. This is especially the case when the small bones 
of the hand are affected. In such cases a tuberculin test is indicated. 

Sudden painful swelling of the long bones occurring in corre- 
sponding bones on both sides should awaken a suspicion of syphilis.. 
even in the absence of other signs of syphilitic disease. A long bone 
which has been affected by syphilis will be irregularly thickened, 
owing to the repeated attacks of periostitis. This thickening i s likely 
to be confounded with that caused by rachitis. 

In rachitis, the bone is less painful than in syphilis and the 
thickening i s invariably uniform and smooth. In scurvy there 
may be a thickening of the long bones due to hemorrhage in the 
periosteum. In these cases (he history and also the presence of other 
signs of scorbutus, such as hemorrhages in the skin or bleeding of 
the gums, will aid diagnosis. 



756 DISEASES OF THE BONES. 

Craniotabes. — In locating patches of so-called craniotabes, the 
surface of the occipital and other bones of the skull is examined for 
deficiency of bone formation. The occipital bone will in rachitis 
present membranous spots more frequently than is generally sup- 
posed. The most common tumors found on the scalp are those due to 
traumatism at birth, such as cephalhematoma, tumor of the scalp 
with depressed bone, and tumor due to syphilis. The cephalohsema- 
toma is found after birth and need not be described here. If an 
infant falls on one side of the head from a height, a depression of the 
skull may at once take place. This occurs if the bones are soft and 
not yet completely ossified. The depression is filled with an effusion 
of blood and serum. A soft tumor results which may not project 
above the surface at all or only slightly so. Around the border of the 
tumor the rim of bone bordering the depression can be felt. In this 
respect the condition differs from the cephalic hematoma found after 
birth. In the latter, the whole tumor is raised from the surface, and 
on physical examination there are no evidences of depression. 

Syphilis. — Syphilis (Fig. 92) may cause the formation of tumors 
on the surface of the frontal and parietal bones varying from the size 
of a hazelnut to that of a walnut. They may at first be hard and 
subsequently soften. They resemble abscesses, and should be differ- 
entiated from them. Tuberculosis of the bones may also cause such 
tumors. Tuberculosis of the skull bones in infancy is of rarer occur- 
rence than syphilis of the skull, the cases of mastoid disease being 
excepted. In a concrete case, syphilis should be assumed until it can 
be excluded. The difficulties of diagnosis may be cleared by a tuber- 
culin test. Abscess may be diagnosed if there are abscesses elsewhere 
in the body. This is the case in folliculitis abscedens of Escherich. 
Mistakes rarely occur in these cases, since all the signs of abscess are 
present. 

Acute Infectious Osteomyelitis. — Osteomyelitis is an acute in- 
fectious inflammation of the structure of the bones. It is common in 
infancy and childhood. Of 50 cases below the thirteenth year col- 
lected by Blumenfeld, 50 per cent, were under five years of age. 
The sexes were equally affected. 

Etiology. — In the majority of cases the essential cause is the 
Staphylococcus pyogenes aureus. The disease may, however, be 
caused by any pyogenic micro-organism, such as the Streptococcus 
pyogenes, the pneumococcus, the Bacillus typhosus, the Recurrens 
spirillum, Bacterium coli, and the gonococcus. Of 90 cases collected 
and reported by Lannelongue, only 10 were due to the streptococcus. 
Lannelongue and Achard were the first to show that osteomyelitis may 
be caused by streptococci in 1890. Van Arsdale and the writer, in 
1891, published 4 cases of osteomyelitis caused by streptococci. These 



DISK ASUS OF TEE BONES. 757 

occurred in newborn infants or followed scarlet fever and pneumonia. 
The streptococcus osteomyelitis is of especial interest to the physician, 
as it occurs in infants and children under two years of age. It fre- 
quently follows infection of the umbilicus in the newborn infant, the 
exanthemata (scarlet fever and measles), and pneumonia. It differs 
from the staphylococcus variety in that the inflammation of the bone 
is less likely to involve the medullary canal, but affects the epiphysis. 
There is also involvement of the joints, with suppuration. The 
bacteria gain access to the circulation (Garre), and to the bones 
through some wound, such as the umbilicus ; through the mucous 
membranes, as in ulcerations of the mouth; through some lesions of 
the skin, such as an eczema or furuncle, or through the gut. Of the 
47 cases cited above, 17 were due to trauma, and 5 followed infectious 
diseases. The causative bacteria are found in the joints and in cases 
of sepsis in the blood. 

Pfisterer has recently published 7 cases of arthritis caused by the 
pneumococcus. In most of these cases the disease was monarticular ; 
though in one case several joints were involved. The arthritis of 
this variety for the most part involves the larger joints. The symp- 
toms are similar to the streptococcus form, and yield kindly to treat- 
ment. Some of the cases may complicate a pneumonia, or they may 
also occur independently of this disease. If complicating a pneu- 
monia, the affection may appear from the first to the ninth week of 
convalescence. 

Morbid Anatomy. — The seat of inflammation is the periosteum and 
the medullary substance of the bone chiefly. The inflammation of 
the marrow and spongy part of the bone involving the cortical bone 
layer is often spoken of as osteitis, that of the periosteum as periosti- 
tis. There is a primary form and one secondary to infections else- 
where in the body. It is a disease of young people and involves 
mostly the long bones. The periosteum is swollen, hyperaemic, the 
seat of hemorrhages and finally of purulent infiltration. The bone 
marrow and neighboring bone tissue is hyperaemic, the seat of hem- 
orrhages, and after a time purulent infiltration. The whole marrow 
canal may be converted into a pus cavity, and pus may form und< r- 
neath the periosteum. The bone tissue becomes infiltrated with pus, 
breaks down and forms sequestra. Abscesses may form in the bone. 
In the subsequent history ofthe separation of the diseased from the 
healthy bone the processes are those seen in all bone inflammations. 

Symptoms.— In older children, the symptoms differ little from 
those ofthe adult subject. The femur and tibia are mosl commonly 
Involved ; next the humerus, superior maxilla, inferior maxilla, ileum, 
and radius, in the order named. In some cases the onsel is sudden 
and the fatal issue takes place in a few days. In others, the h 



758 DISEASES OF THE BONES. 

sion is gradual. In older children there are the regular symptoms 
of chill, fever, and vomiting, followed by local symptoms. 

In young infants the signs of osteomyelitis are obscure. In the 
puerperal cases in newborn infants, the umbilicus may be inflamed 
for some days, after which the infant begins to cry when handled in 
the bath. The umbilicus may be healed and the symptoms referable 
to the joints may not appear until weeks after birth. One extremity is 
not moved and a joint may be swollen (Plate VII.) . Swelling of the 
joint may escape notice until the child is examined by the physician. 
After scarlet fever, the swelling of the joints is quite apparent, and 
also after pneumonia. In the newborn infant several joints may be 
swollen. In one of my cases in an infant ten months old, the elbow- 
joint and wrist-joint were involved, the whole radius being the seat 
of osteomyelitis. Similar cases have been published in this country 
by Gibney. The frequency of joint-involvement is a feature of 
osteomyelitis in children. Of 50 cases of osteomyelitis published by 
Blumenfeld, the joints were involved in 30. I have seen the multiple 
joint-suppurations most frequently in newborn infants. In all cases, 
there are evident swelling of the tissues about the joints and fluctua- 
tion in the joint-cavity. The joint contains pus. 

Bacteria are found in the pus and in the blood. In the newborn 
a meningitis of the same bacterial nature as that of the joints may 
close the symptomatology. 

Diagnosis. — The diagnosis is not difficult. If an infant cries when 
it is handled; every joint should be carefully examined. Osteomyeli- 
tis may be confounded with scorbutus. In the latter affection, the 
joints are painful and swollen, but do not contain fluid. In scorbutus 
there are ecchymoscs, swelling and sponginess of the gums, and 
hemorrhagic lesions underneath the skin, all of which will aid in 
diagnosis. A history of umbilical inflammation or of scarlet fever 
is of great value. There are in congenital syphilis of young infants 
forms of inflammation about the joints which at first simulate 
osteomyelitis. In such cases the infant should be examined for other 
evidences of congenital syphilis, such as fissures and rhagades about the 
mouth and anus, mucous patches, and coppery discolorations of the skin. 
Tuberculous inflammation in the long bones or in the heads of the 
bones may present some difficulties of diagnosis. A study of the # case 
and the absence of a history of acute trouble will solve the difficulty. 

Prognosis. — The prognosis of acute osteomyelitis in newly born 
infants is grave. The majority of cases are fatal owing to the form- 
ation of multiple foci of suppuration. The prognosis is also grave in 
infants under one year of age. The mortality of all cases under the 
fifth year is 56 per cent. In older children it is 20 per cent. 

Treatment. — The treatment of acute infectious osteomyelitis is 
surgical. 



SECTION XIII. 

DISEASES OF THE EAR. 

Otitis in Infancy and Childhood. — Frequency. — Otitis media, ca- 
tarrhal or purulent, is a very common disease of infancy and child- 
hood. It is, as a rule, a secondary affection, but may in rare cases 
occur as a primary disease. Parrot first called attention to the fre- 
quency of otitis as a complication of bronchopneumonia. ^Tetter made 
the first bacteriological examinations of the discharges from the ear. 
The subjects were 20 children whose ages ranged from nine days to 
two years. Kossel, Rasch, and Ponfick have investigated the fre- 
quency and nature of this affection in children. The results of their 
work show striking uniformity. Fully 85 per cent, of infants and 
children, examined post mortem, were found to have diseased ears. 
Most of the infants, especially those examined by Ponfick, had died 
of gastro-enteritis, acute or chronic. Some had suffered from gastro- 
enteritis, pneumonia, or congenital syphilis. 

Etiology. — The etiology of acute catarrhal, acute suppurative otitis 
media and of acute suppurative mastoiditis is much the same. The 
naso-pharynx and the Eustachian tube are normally the habitat of 
various forms of bacteria. This is the case in infants and children 
who have enlarged tonsils and adenoid growths. " A reduction of the 
vitality of the individual or any acute disease favors invasion of the 
ear by bacteria entering the Eustachian tube. Thus the exanthemata, 
especially scarlet fever and measles, furnish a large quota of cases. 
Diphtheria, typhoid fever, typhus fever, varicella, influenza, gastro- 
enteritis, tonsillitis, and simple angina, also cause a large number of 
cases of otitis. Pertussis, cerebrospinal meningitis, and pneumonia 
are complicated by the disease. Sea-bathing, exposure to cold, and 
nasal douching favor its onset. 

Bacteriology. — The bacteria found by different observers in the 
otitic discharges and in the cavities of the ear include the Staphy- 
lococcus pyogenes aureus, citrous, and albus, the Streptococcus pyo- 
genes, the pneumococcus of Frankel, the influenza bacillus and 
pseudo-influenza bacillus, the Bacillus fcetidus, and the Bacillus pyo- 
cyaneus (better, Kossel, Ponfick). The streptococci and influenza 
bacilli cause an especially severe inflammation, the pneumococcus a 
milder form. The diphtheria bacillus also causes otitis. 

Morbid Anatomy.- In both forms of otitis and also in mastoid 
disease the tympanic membrane is injected and the vessels at its 

759 



760 DISEASES OF TEE EAE. 

border are increased in size. The vessels of the hammer are injected. 
The epidermis of the tympanic membrane may be intact. The tym- 
panic cavity may be filled with cellular elements. There may be a 
serous, mucous, purulent, or mucopurulent exudate. The mucous 
membrane of the tympanic cavity may be intact but injected, or may 
show gross defects. If the bony structures are involved, there will be 
necrosis of bone, especially of the tegmen tympani. There may be 
perforation of this structure or of the point of the mastoid process. 
The dura mater or sinuses of the dura may, in progressive mastoid, 
be inflamed. There may be cerebral abscess. If the pus does not 
escape by way of the Eustachian tube, it may perforate the tym- 
panum. The exudate which fills the tympanic cavity contains epi- 
thelial cells, leucocytes, and blood-cells. 

Otitis Media Catarrhalis. — Acute catarrhal otitis is, in a vast num- 
ber of cases, simply a forerunner of otitis media purulent a or of an 
acute suppurative otitis. It will be convenient for the practitioner 
to consider these affections together. 

They are more common among infants and children than among 
adults, and may occur at the earliest period of infancy. They occur 
most frequently, in the spring and summer. 

The causation has been considered under the etiology, and is the 
same in both affections. 

Symptomatology. — In young infants and in children under two 
years of age, the symptoms are frequently masked by those of the 
primary disease. In many cases, the otitis gives no special warning 
of its presence. Perforation of the drum and a purulent discharge are 
the first intimation of the condition. This is especially the case in 
otitis in young nurslings who have suffered from acute tonsilitis or 
pneumonia, but these are not the cases which the practitioner is called 
upon to diagnose. 

In another set of cases, especially in those in which otitis is 
coincident with gastro-intestinal disorders of a chronic type, tending 
to atrophy, Heermann and Ponfick have shown that during life the 
otitis gives no objective symptoms although on otoscopic examination 
the tympanic cavity is found to be filled with pus, so-called marantic 
cases. In cases which follow the milder types of influenza or angina, 
there may be a most puzzling set of symptoms which can only be 
referred to the ear. In these cases the physician finds, two or three 
days after the onset of tonsillitis or influenza, that the temperature 
does not drop to the normal; it may mount to 104° F. (40° C.) 
toward evening, and in the morning may drop to or within a degree 
of the normal. While the temperature is low the infant takes its 
food and plays. When it rises the infant becomes fretful, or stupid, 
or sleeps most of the time. There is no indication of pain. 



OTITIS IN INFANCY AND CHILDHOOD. 



61 



In other cases the infants will start from sleep and cry with pain. 
In some cases the infants perspire freely at the falling of the temper- 
ature. These simulate in many respects cases of malaria or of 
meningitis of the tuberculous type, except that the temperature rises 
higher than in the latter disease (Fig. 172). Local facial pareses 
may complete the resemblance to meningitis. The intermittent or 
recurrent curve of temperature may continue for a week or ten days. 
Only the careful exclusion of disease of other organs, and especially 
of the lungs and of the heart, will lead the physician to suspect disease 
of the ear. In nursing infants the bowels will be abnormal and the 
movements greenish, containing white curds. The temperature is, 
however, much higher than in any diarrhoea, and is more persistent 
and regular in its daily fluctuations. 

Fig. 172. 



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53 


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Otitis media purulenta in a child eighteen months of age. Symptoms and curve simu- 
lating closely a meningitis of the basal type. 



In cases of broncho-pneumonia complicated with otitis, previous 
to the spontaneous perforation of the drum the temperature will have 
shown more decided fluctuations than would occur at a late stage of 
the primary disease. However, in pneumonia there are few or no 
objective signs of the affection. Older children may have certain 
definite symptoms such as dull headache and pain in the ear, which, 
if sharp and stinging, will cause them to start in sleep, or to awake 
and cry out or put the hand to the ear. This last sign, so often men- 
tioned in the text-books, I have seldom seen. There may be delirium 
and the fever may be quite high. Children who can talk complain 
of pain at night. There may be rushing, singing, or buzzing noises 
in the ear. Very characteristic is the starting of infants during 
sleep. Older children are out of sorts, and angry on awakening. 

Course. — Spontaneous perforation in a number of cases occurs 
in a few hours or a few days after the onset of the disease. As a 
rule, however, pain continues with fever until artificial paracentesis 
of the drum is practised. After spontaneous rupture oi the. tympa- 
num, or paracentesis, the discharge may continue, beino- in sonic cases 
serous or serosanguinolent, and later becoming purulent. The puru- 
lent discharge may be profuse and the disease mav advance into the 



762 



DISEASES OF TEE EAB. 



mastoid or labyrinth. This frequently occurs in cases of the ex- 
anthemata or in pneumonia or influenza. In severe cases, the 
discharge may continue and become chronic, resulting in destruction 
of the structures of the ear. Complications may intervene, such as 
facial erysipelas, meningitis, cerebral abscess, thrombosis of the 
cerebral sinuses, and finally in suppurative cases pyaemia may inter- 
vene. On the other hand, after spontaneous rupture or paracentesis 
of one or both drums, the serous or purulent discharge may gradually 
cease and the ears be restored without any defect of hearing. In 
many cases incision of the drum in the early stages of the disease is 
not followed by the discharge of pus; the symptoms cease, and the 

Fig. 173. 




Examination of the ear with head mirror and reflector. 



patient recovers. In other cases there is no rupture of the tym- 
panum, although the tympanic cavity is filled with exudate, which 
discharges through the Eustachian tube. The pus may be swallowed 
and cause diarrhoea or pneumonia. In the cases of marasmus with 
otitis described by Heermann, the pus is believed to have found its 
way from the middle ear through the tube to the nasopharynx. 

Method of Examination of the Ear in Infants and Children. — The 
examination of these young patients must often be made at the bed- 
side, where the examiner does not have all the conveniences of the 
office equipment, so that he should be prepared for the use of the 
head-mirror with the light from a candle or a kerosene lamp which is 
still better. 

If the examiner is myopic, this is in his favor, but if he has 



OTITIS IN INFANCY AND CHILDHOOD. 



763 



hjpermetropia or is presbyopic, the necessary correcting glas 
should be worn, for without good vision for the near-point, it will be 
difficult to make out any details. 

If there are no contra-indications such as weak cardiac action, 
the young patient should be placed in an upright position on the lap 
of an assistant and the entire body from the neck downwards should 
be wrapped in a blanket or sheet, with the arms down and fully 
extended alongside of the body (Fig. 173). 

Fig. 174. 




Examination of the ear with the electric headlight. 



The assistant holding the child should be seated on a firm chair 
with a back. In the examination of the right car, the assistant 
presses the back of the child's head against the chest, by holding the 
patient's forehead with the left hand, and for the left ear. vice versa, 
— care being taken that the other arm firmly encircles the child's 
body and arms. 

[f the electric head-light is used, or the electro-otoscope or a 
nearby gas or electric light, no further assistance will be required. 
but if a candle or kerosene lamp is brought into requisition, a third 
party may be needed to hold the lighl a little above and behind the 
patient's head (Fig. 174). 

Furunculosis and impacted cerumen are very infrequenl among 
children, but foreign bodies such as peas and pebbles and small 
insects must be considered as likely to obstruct vision. 



764 DISEASES OF THE EAR. 

One of the greatest obstacles to a proper examination of the mem- 
brana tympani in children is the presence of exfoliated epithelium 
which is often pulpy in consistence and covers the external surface of 
the membrana tympani in a thin layer, thereby hiding the details of 
its appearance. 

The presence of this deposit indicates an inflammation of the 
tympanum often only of a sub-acute type, but which has been present 
for some days. The removal of this deposit by irrigation with a 
warm borax solution will reveal the surface of the tympanum. 

In selecting a speculum one should be chosen which does not crowd 
the canal, as this is also apt to give unnecessary pain, and when 
introduced, it should be inserted by a revolving motion. It must be 
remembered that the plane of the drum-head lies more horizontal in 
the young than the older subject, and in making traction upon the 
auricle, one should make traction somewhat downwards and back- 
wards, instead of upwards and backwards as in older subjects. 

In cases where there are large sub- or retro-maxillary glands, the 
floor of the canal may have been pushed upwards so that it is some- 
times almost impossible to see the fundus of the canal even with the 
smallest speculum. In such cases it is best to pack a little strip of 
gauze into the canal for a few hours, and upon its removal the canal 
will be sufficiently dilated to permit of the introduction of a speculum. 

In all cases, both ears should be examined, even though we have 
manifest evidence of disease in one ear only. 

Diagnosis. — The diagnosis is first made from the rational symp- 
toms. In my experience, the temperature-curve is a very useful 
guide in infants who give no evidence of pain. Otoscopic examina- 
tion is the only positive means of making a diagnosis. There is 
congestion of the tympanum above Shrapnell's membrane and the 
long handle of the malleus. In the catarrhal cases the tympanum 
is red and angry or has a grayish lustre. The handle appears as 
a red or yellowish-white point. In some cases there are vesicles and 
interlamellar abscess. The exudate may cause bulging of Shrap- 
nell's membrane or of the posterior-superior quadrant. Congestion 
remains long after resolution. In the suppurative cases the epithe- 
lium of the tympanic membrane may peel off. The tympanum is 
dull and lustreless. The auditory canal may be swollen. Perfora- 
tion occurs, chiefly in the posterior-inferior quadrant. There may 
be pulsation of the membrane as well as bulging. The lymph- 
nodes beneath the ear may enlarge and that region may be very 
sensitive. 

Prognosis. — The prognosis in ordinary cases is good. In cases 
following the exanthemata it is grave, on account of the possibility 
of complications and of ultimate loss of hearing. 



MASTOID DISEASE. 



765 



Fig. 175. 



Mastoid Disease. — General Facts. — The mastoid region is impor- 
tant on account of the frequency of mastoid disease in infancy and 
childhood. In early life there is pneumatic tissue, but no mastoid cells 
are found. The mastoid process contains one large cell (Symington) 
(Fig. 175). The external wall is less thick and compact than in the 
adult. The petrosquamous suture is patent. The petrosquamous 
sinus is persistent in some cases, passes through a foramen on the 
inside of the skull, and appears externally behind the glenoid fossa 
and tympanic ring. Thus infectious material may easily be con- 
veyed internally. In infants and children pus finds its way exter- 
nally more readily through the open flssura mastoideo-squamosa. 

Etiology. — Inflammation of the mastoid 
is rarely primary. The mastoid may at 
the outset be inflamed when there has been 
no antecedent otitis. As a rule, however, 
inflammation of the mastoid is secondary 
to acute or chronic otitis. The causation 
is identical with that of acute or chronic 
otitis. 

Of 39 cases of mastoid disease under 
eight years of age, collected by Knapp, 7 
occurred in the first year, and 9 in the 
second. The greatest frequency is there- 
fore after the second year. It may occur 
as early as the second month. I have had 
a case in an infant three months of age. 
The anatomical conditions favor the occur- 
rence of mastoid disease in infancy and 
childhood. The Eustachian tube is short and of large calibre ; infec- 
tions material from the nasopharynx can easily gain access to the ear. 

Symptoms. — Clinically, mastoid disease in infancy and childhood 
manifests itself by rational symptoms and physical signs. There may 
be extensive mastoid disease without any external physical signs. In 
one of my cases of otitis, which was observed by an expert from the 
outset, extensive mastoid disease in a child of three years of age did 
not give any external signs. The clinical symptoms are character- 
istic. The drum may have been perforated after otitis, or paracen- 
tesis may have been performed. After perforation, the temperature 
present during the preceding otitis drops to the normal. The patient 
is able to be up and about. The ear discharges freely. 

After two or three weeks there is a sudden or gradual rise of 
temperature, which may be slight or may reach 103° or 105° V. 
(39.4° to 40.5° C). There is restlessness at night. On inspection, 
the ear may nol show anything abnormal. The temperature, how- 




US. 

Coronal section of the 
mastoid process in an infant 3 
months of age. This is the 
infantile type of mastoid. 
(Symington.) 



766 



DISEASES OF THE EAR. 



ever, continues to be remittent for several days. On otoscopic 
examination, there is found to be swelling of the roof of the auditory 
canal or of the floor of the attic. In other cases, after a very early 
and timely paracentesis of the drum, the patient does not do well. 
The child is restless at night, at intervals irritable and then playful, 
and starts from sleep (Fig. 176 J. The temperature fluctuates daily 
from 100.8° to 102° F. (38.8° C). On some days it may be normal 
or subnormal. The ear discharges for days, but a slight temperature 
continues. 

If the patient is an infant or a young child, it may be very diffi- 
cult to ascertain whether pain is present on pressure backward over 
the region of the antrum behind the ear. There is in early cases no 
swelling or redness behind and above the auricle. As was stated 

Fig. 176. 



DAY OF 
DISEASE 


9 


10 


11 


12 


13 


14 


15 


16 


17 


18 


19 


20 


21 


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23 




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= 2|=2 


=J2 


= 2 


= 2 


= 2 


= 2 


--2 


= 2 


=|2 


»|2 


=b 


= 2 


= 2 


--2 


104° 
2 103° 
< 102 c 

"T ioi° 

1 ioo c 

H 99 c 


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H 


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t=> 1 1 1 1 1 1 1 1 tf\=fcfc 














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RESP. 




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55 






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Otitis media in a female child, three years of age. Observed from the onset. Early 
paracentesis, fall of temperature, then rise again. Subsequent mastoid involvement 
necessitating operation. 



above, there may be extensive and advanced mastoid disease without 
external redness or swelling. In such cases the lymph-nodes behind 
the ear and at the angle of the jaw may be swollen and painful. 
Young children and infants do not complain of pain. It is only in 
older children that it can be noted. 

Mastoid disease which follows the exanthemata, especially scarlet 
fever or measles, or occurs late in typhoid, shows certain charac- 
teristic clinical features. During the fifth or sixth week of scarlet 
fever the ears may discharge profusely. There is a daily rise of 
temperature in the afternoon, which is slight in some cases. The 
patients play in the early portion of the day, but in the afternoon 
appear listless, and have a slight frontal headache. As days pass, 
the children become stupid during the afternoon rise. 

In many cases of scarlet fever otitis is a complication. The tem- 
perature does not fall to the normal, as it should, after the fading of 
the eruption. There is slight aural pain at night, which is sometimes 
sufficiently severe to deprive the patient of sleep. In other cases the 
temperature drops to the normal and suddenly rises in the second 



MASTOID DISEASE. 



767 



week. In both these sets of cases there is an otitis which may develop 
into mastoid disease, or in which mastoid disease may have beeu 
present from the outset. 

Korner calls attention to the fact that in late typhoid fever, chills, 
with rises of temperature, may be, in the absence of other signs, 
indicative of serious mastoid disease. 

Physical Signs. — Pain. — Pain is a physical sign of mastoid dis- 
ease in children. In most cases it cannot be elicited by the most 
skillful manipulation. In others, on account of the fear and rest- 
lessness of the patient, it is impossible to come to a definite conclu- 
sion. In older children pain may be elicited by pressing the mastoid 
bone in a backward direction, care being taken not to press on the 



Fig. 177. 




Mastoid disease in a child eighteen months of age. Swelling behind the ear over the 
mastoid. The ear is displaced away from the scalp. 

auricle. The pressure should be firm and continuous. Pain in the 
tip of the mastoid is not of value unless there has been a perforation 
and phlegmon at that point (Dench). 

Otoscopic Examination. — There is a shortening of the external 
canal in its posterior and upper aspect (Dench)/ The upper pos- 
terior wall sinks. There is bulging f the upper portion of the 
tympanum. 

Tumefaction, Tumefaction posteriorly and above the external 
structures of the ear occurs in infants only in neglected cases, \ 
cording to Dench, in these eases the pus escapes from the antrum 
through the auditus ad antrum into the tympanic vault. It then 
finds its way through the Rivinian fissure along the upper wall of 



768 • DISEASES OF THE EAR. 

the canal to the external surface of the mastoid. In children cases 
in which this swelling appears are less serious than adult cases. 
The swelling also appears much earlier in infants and children. 

Diagnosis. — The life of the patient often depends upon the early 
recognition of mastoid disease. The diagnosis in infancy and child- 
hood should not only be made early, but should be made chiefly from 
the clinical symptoms of temperature, which will in its fluctuations 
show a septic curve, and from the physical signs and otoscopic exami- 
nation. The history of the case is of service. Presence of pain is 
of no value in infants and young children. The daily otoscopic 
examination of the discharging ear will give positive evidence of 
mastoid disease. The signs detailed in the paragraph on symptoms 
are of great importance. A profuse discharge does not preclude 
mastoid disease. Facial paralysis is of no value. I have seen it in 
cases in which mastoid disease was on operation found to be absent. 
Tumefaction is seen only in late cases. Redness is sometimes ap- 
parent before the appearance of swelling behind the ear. 

Course. — In neglected cases pus from the mastoid may force its 
way through the tympanic roof and cause cerebral abscess or menin- 
gitis. It may destroy the plate (lamina vitrea) of the sigmoid sinus 
and cause thrombosis, may find its way through the tip of the mas- 
toid along the border of the sternomastoid, and cause phlegmon, or 
may force itself through the sutura mastoideo-squamosa, causing 
swelling behind the auricle. 

Treatment. — Prophylaxis. — Children can be taught to tolerate 
the therapeutic measures which, if catarrhal inflammation of the 
fauces is present, as in the exanthemata, will cleanse the parts. Thus 
in scarlet fever, an intelligent child will readily allow the throat to 
be sprayed with normal salt solution. Swabbing the throat or apply- 
ing any drug locally is impracticable in children. 

If the pain is excessive a mild opiate, such as paregoric, is 
administered. In young infants the severity of pain cannot be esti- 
mated. In older children dry heat applied externally to the ear by 
means of a water cushion relieves the pain. Some authors advise 
the application of leeches behind the ear, or the instillation of water 
at 110° F. (43.3° C.) into the canal with a dropper. Inflation of 
the ear in the early stages of otitis media has been advocated and 
condemned. 

Suction by means of a catheter introduced into the Eustachian 
tube is also practised. If the pain and fever are not relieved by 
these measures, incision of the drum is resorted to. Whether the 
otitis is catarrhal or purulent, paracentesis is best performed early, 
since damage to the ear may thus be avoided. The method of per- 
forming paracentesis of the drum is best learnt from special text- 



MASTOID DISEASE. K'/-) 

books on the subject. Duel advises enlargement of the opening in 
cases in which spontaneous rupture of the drum has taken place. 
Drainage by the introduction of sterilized absorbent gauze into the 
canal is superior to syringing. If this is not possible, syringing 
with 1: 5000 bichloride is useful. 

The indications for the performance of mastoid operation are 
protracted otitis with profuse otorrhoea, there being no tendency to 
resolution, acute otitis in which there is a tendency to resorption 
and in which paracentesis has not established drainage, also muco- 
purulent otitis maintained by mastoid involvement, otitis with symp- 
toms pointing to meningeal complications, and finally otitis with 
complicating stenosis of the external canal, preventing drainage. 



49 



SECTION XIY. 

DISEASES OF THE KIDNEYS AND UROGENITAL 

TRACT. 

The weight of the kidneys is M20 of the body weight in the 
infant and %40 in the adult. 

It is not, as a rule, possible to palpate the normal kidney in the 
infant or child. I have, however, seen in young infants exceptional 
cases in which the kidneys were situated very low down and could 
be easily palpated through the abdomen. I have found floating 
kidneys in infants and older children, but not so frequently as other 
observers. Comby in 1898 reported 18 eases, of ages ranging from 
one month to ten years of age. Steiner. Stewart, and Abt have also 
reported a number of cases. I believe that the displaced and fixed 
kidney is congenital. As the child grows and the parts are stretched, 
the attachments of the kidneys, congenitally low, become more re- 
laxed. This would account for a number of cases. Jacobi believes 
that floating kidney in children is a congenital anomaly. 

Sixteen of Comby's cases occurred in girls. A displaced, fixed 
kidney in infants causes no symptoms. In cases of movable kidney 
or floating kidney the main symptom is pain, either epigastric or 
radiating from the iliac region. In a girl of eight years with float- 
ing kidney, there was no difficulty in palpating the enlarged movable 
kidney below the liver. There were attacks of acute colicky epigas- 
tric pain, which occurred independently of the ingestion of food. 
The child was nervous and hysterical. 

DISEASES OF THE KIDNEY. 

Cyclic Albuminuria {Postural Albuminuria; Orthostatic or Lor- 
dotic Albuminuria). — Cases of this form of albuminuria were first 
published by Vogel, Ultzmann, Gull, and Leube. The systematic 
description was first given by Pavy, by whom it has been carefully 
studied. 

Cyclic albuminuria occurs principally in children and adoles- 
cents ; 40 per cent, of the cases occur in children from the first to the 
fifteenth year, and 80 per cent, of the cases occur before the twentieth 
year. Jehle places the greatest frequency from the sixth to the four- 
teenth year. It is, therefore, distinctly a disease or condition ob- 
served in a period of metabolic activity and growth. 

770 



DISEASES OF TEE KIDNEY. 11 \ 

The characteristic symptom is the appearance of albumin in the 
urine in the forenoon and afternoon, and its disappearance after a 
night's rest in the recumbent position. It is not present in the morn- 
ing directly after rising, but appears soon after the upright position 
has been assumed. 

Mode of Occurrence.- — Heubner traces a connection between this 
form of albuminuria and the position of the body. He finds that 
patients excreted albumin when their position was changed from 
recumbent to the upright posture; therefore, during rest in bed there 
is, in such individuals, no albuminuria. But it regularly appears 
when they get out of bed and exert themselves. He therefore pro- 
posed the term orthostatic albuminuria for these cases. 

Etiology. — Jehle points out the relationship of this form of albu- 
minuria to lordosis of the lumbar vertebras. In children having a 
marked lordosis in the upper part of the lumbar spine albuminuria 
occurred in the upright military position or in normal children in 
whom an over-accentuation of the normal lordosis was produced arti- 
ficially or by some form of exertion. The lordosis causes the albu- 
minuria by a change in the circulatory conditions of the kidney. The 
greatest frequency of an abnormal lumbar lordosis and therefore of 
the albuminuria occurred in children from the sixth to the fourteenth 
year. There was a slight preponderance of the female sex. 

There is no doubt as to the existence of this form of albuminuria 
in children, but its significance is a matter of wide diversity of opin- 
ion. Heubner has published some cases and collected 22 cases in 
children from one to fifteen years of age. Some authors, among 
them Heubner, are inclined to regard them as physiological forms of 
albuminuria. Others, among them Henoch, Leube, and Senator, are 
inclined to regard them as due to insidious changes in the kidney 
following infectious disease. It should be remembered that after 
influenza, scarlet fever, or diphtheria, small quantities of albumin 
are, at intervals, present in the urine for months and years. There 
may also be occasional hyaline or epithelial casts and a few blood- 
cells. These disappear either with or without treatment of diet and 
rest, but later reappear. I have seen this occur in children in good 
health. 

Symptoms. — The Urine. — The albuminuria occurs in from one to 
three or five minutes after the erect posture is assumed. The amount 
of albumin varies from a trace to a heavy precipitate. 

The presence or absence of form elements from the kidney has 
been a matter of much discussion as to the correct interpretation of 
their presence. Some observers (Heubner, Langstein) look upon 
casts and blood and eylindroids as a sign of disease ol the kidney, 
but Jehle goes so far as (o insist that at the nionieni o\ the greatest 



772 DISEASES OF KIDNEYS AND UROGENITAL TRACT. 

albuminuria, casts, granular, hyaline and cylindroids, and even blood, 
may appear to disappear when the so-called insult is removed from 
the kidney in the absence of any nephritis. Such a view would 
appear to require some confirmative observations. It should be 
remembered that, in nephritis, the albumin in the urine frequently 
takes a cyclic course (Senator). 

Prognosis and Course. — The prognosis must remain conditional 
on the prolonged observation of the patient if there is albumin 
in the urine, for a few of the published cases have in later years 
developed nephritis. It is said, also, that this form of albuminuria 
has been met in several members of the same family, and in fami- 
lies in which albuminuria and nephritis have existed. The term 
cyclic albuminuria should, it seems to me, for the present be lim- 
ited to those cases in which there has never at any time previous 
to or during observation been any form-elements of the kidney in 
the urine. Many of the cases published, and those which I have 
observed, occurred in children with lymphatic constitutions; in 
others there was scrofulosis and tuberculosis (Pfaundler). They 
showed a marked ana?mia at times. There was an oedema of the face 
but not of the extremities. The children complained at various 
times of headaches or a heavy feeling in the occiput, were easily 
tired, awoke feeling tired. They were subject to dreams and were 
of a nervous temperament. In one of my cases the child was free 
from the above symptoms, and was the picture of health. In this 
case there were periods early in the disease in which very scanty 
form-elements occurred in the urine wuth the albumin ; at others, 
none could be found. The case was at first diagnosed as cyclic albu- 
minuria ; but my fears have been justified, inasmuch as lately the 
form-elements, such as casts and blood, have increased in the urine 
and have become permanent, thus showing the danger of diagnosing 
these cases on short periods of observation. Two cases which I have 
seen, after many repeated examinations (extending over a year) of 
the urine, failed to reveal anything pointing toward an affection of 
the kidney. The albuminuria is present some time after rising in 
the morning, and after exercise. It disappears on enforced rest. 

Treatment. — It has been proposed in cases of cyclic albuminuria 
to enforce at intervals periods of rest of one or two weeks at a time, 
and the limitation of exercise and sports. I have tried this method, 
at the same time dieting the patient, but have not found it as suc- 
cessful in improving the general condition of the patient as moderate 
out-door exercise in the open high country- — freedom from mental 
worry 3 such as the suspension of studies ; good, simple food ; perhaps 
a tonic of the iron series. City and school life are not conducive to 
aiding the physician in treating these cases. A persistent ana?mia 



DISEASES OF THE KIDNEY. 773 

sets in under these conditions, and is the symptom that baffles the 
physician in the treatment. Nothing will improve the patient so 
much as out-door exposure in the open country. 

(Edema or Hydremia without Kidney Lesion. — Weak infants 
who have suffered from chronic gastro-enteric catarrh have swelling 
or an oedematous condition of the dorsum of the feet and ankle-. 
There may be slight anasarca elsewhere. There is no real kidney 
lesion ; the condition is one of hydrsemia. The changed state of the 
tissues, including the vessels and blood, allows of a transudation of 
serum into the subcutaneous structures. On examination, the urine 
is found to be abundant and of low specific gravity, but without evi- 
dences of nephritic degeneration. In children of two years of ago 
this condition of slight subcutaneous oedema occurs in simple anaemia 
of a severe type. In these cases the skin is yellowish, the ears have 
a waxy clearness, the eyes have an oedematous appearance, and the 
lips, hands, and feet are puffy. The condition is known as hydrsemia 
or hydra?mic ansemia. 

Dysuria. — Dysuria, or difficult and painful micturition, is a con- 
dition in which there is partial obstruction to the free flow of urine 
from the urethra. It is not uncommon in young infants and chil- 
dren, and may be due to a variety of causes. If lithiasis is the cause, 
there is not only pain in passing the urine, but there may, in the 
intervals, be acute attacks of pain, due to the passage of calculi along 
the ureter. Examination of the urethra in the male often results in 
finding a calculus of very small size in the anterior penile urethra. 
In lithiasis, there is sometimes very painful micturition without the 
formation of calculi of any size. The minute crystals of uric acid 
cause a smarting sensation as the urine passes over the urethra. In 
febrile states with concentrated urine, the acidity of the urine, and 
the excess of uric acid with free crystals, cause painful micturition. 

Simple or gonorrhoeal inflammation of the urethra may cause 
difficult and painful micturition. Dysuria is painful at the onset of 
vulvovaginitis. 

Cellular Atresia of Labia. — Another condition of congenital origin, 
which was described by Bokai as cellular atresia of the labia, is a 
very common cause of dysuria. It is seem in very young female 
infants. From birth, the urine is passed in drops and with groat 
straining and pain. In some cases it is passed without pain, but the 
condition of atresia attracts attention. On gently separating the 
labia majora a (bin pinkish-white membrane is seen to occlude the 
introitus vagina 1 completely. At the urethral end o\' this membrane 
a very minute opening is seen, through which the urine filters. 
Those membranes van bo divided by means of a dull director. It i< 
then seen thai the hymen and urethra are directly behind the mem- 



774 DISEASES OF KIDNEYS AND UROGENITAL TRACT. 

brane. The operation of dividing the membrane is exceedingly 
simple and causes little or no bleeding. 

Bokai has described a similar condition in boys, which is some- 
what less common. It is a cellular adhesion of the prepuce and glans 
penis which not only causes false phimosis, but also difficult and 
painful urination. He found that in the newly born infant the 
prepuce was sometimes adherent to the tip of the glans penis, and 
that across the opening of the meatus there was a very thin mem- 
brane. In other cases, this membrane was ruptured, but the prepuce 
still remained adherent to the glans in front 1 , while behind at the 
corona glandis there was retention of smegma and consequent painful 
inflammation. 

The treatment is division and separation of the cellular adhe- 
sions. Other abnormalities in infant boys, among them diverticula 
of the urethra, may cause dysuria. 

Haematuria. — Hematuria is the passage of blood and its elements 
into the urine, in which blood-cells and coloring-matter are found. 
The condition may occur in the following states : 

(a) Acute nephritis of all forms, especially those complicating 
the infections diseases, such as scarlet fever, measles, typhoid fever, 
and malarial fever. 

(b) Calculi, renal or vesical. 

(c) Malignant growths of the kidney — sarcoma and carcinoma. 

(d) Growths of the bladder — polypus. 

(e) Traumatism in the region of the kidney. 
(/) The ingestion of drugs. 

(g) Scorbutus. 

The color of the urine varies from a slightly smoky amber to a 
deep brownish-red. There may be a deposit of blood-cells and clots 
in the urine. Pure blood with clots is seen in cases of malignant 
tumor of the kidney and calculi of the kidney or bladder. Smoky 
urine is seen in cases of nephritis and drug-poisoning. 

Hemoglobinuria. — Haemoglobinuria is a condition in which the 
urine contains the coloring-matter of the blood, but, except in rare 
cases, no red blood-cells. The urine is reddish or brownish, and has 
a high specific gravity. It contains albumin. By spectral analysis 
the spectrum of the blood coloring-matter is obtained. According to 
Hoppe-Seyler, methaemoglobin and not haemoglobin is often the 
coloring-matter present. There are few blood-cells and no detritus. 

Etiology. — Several theories have been advanced to explain the 
appearance of haemoglobin in the urine, that of Ponfick being gener- 
ally accepted. According to that author, either the blood-cells are 
destroyed by some vicious agent or ferment (Ehrlich) and the 
haemoglobin is thus let loose into the circulation, or the haemoglobin 



DISEASES OF THE KIDNEY. 775 

is dissolved out of the blood-cells and passes into the circulating 
plasma, leaving the cells behind as so-called " shadows." Whatever 
the real cause, the exciting influences are: 

(a) Cold or exposure to wet. Hoff and Demme have published 
cases of children with paroxysmal hemoglobinuria following such 
exposure. 

(&) Drugs, such as arsenic, phosphorus, potassium chlorate. 

(c) The infectious diseases, such as malaria and scarlet fever, 
erysipelas. 

(d) Hemoglobinuria has been observed in cases of burns. 

(e) Baginsky has observed hsemoglobinuria in children with 
nematodes. 

One-half the cases published have a history of syphilis. Such is 
the case published by Hermann, occurring in a boy four years of 
age, with a history and physical marks of congenital syphilis. In 
this case the boy had at times attacks of hemoglobinuria. 

Symptoms. — In the paroxysmal form, each attack is preceded by 
a chill and followed by dyspnoea, palpitations, cyanosis, and severe 
symptoms of collapse. The attack may last a few hours or a few 
days, the duration depending on the course of the primary affection. 
This form has been especially observed to occur in pernicious malar- 
ial fever. 

Prognosis. — The prognosis is very good. Patients quickly recover 
from the attack proper, and there is no danger to life. The cases of 
syphilitic origin are not controlled by antispecific treatment, though 
the condition of the blood is improved. Chovostek succeeded in 
abating an attack by the administration of amyl nitrite. 

Morbid Anatomy. — Dieulafoy and Widal found in a fatal case the 
cortex of the kidney dark brown in color ; the cells of the glomeruli 
were normal. The cells of the convoluted tubes and the tubes of 
Henley were infiltrated with pigment-granules, which were also pres- 
ent in the lumen of the tubes. 

Treatment. — The treatment consists not only in the management 
of the primary exciting conditions, but, if there is a history of syph- 
ilis, an antispecific course of treatment is indicated. With this we 
may give tonics, such as iron, and exert a certain amount of pro- 
phylaxis by protecting the patient from cold, and also, if possible, 
securing to the patient wholesome food. 

Renal Calculi (Uric Acid Infarction ; Lithcemia). — So-called uric 
acid infarction is found in the kidneys of over one-half the infants 
who die in the first weeks of life. These infarctions are seen in the 
medullary portion of the kidney as golden-yellow or brownish rays 
which are broader toward the papilla. Epstein found isolated 
deposits in the cortex. The infarctions consist o\' uric acid (Schloss- 



776 DISEASES OF KIDNEYS AND UROGENITAL TRACT. 

berger). They are supposed to be due to the destruction of tissue 
rich in nuclein (cells) (Kossel and Horbaczewski). They are 
found in weaklings, and more often in infants who have been born 
living than in stillborn infants. During the first weeks of life they 
are washed out by the urinary secretion. Hence the increased 
uric acid excretion at that time. As a rule the condition gives no 
symptoms. 

It is not uncommon for the diapers of the infants to be stained 
red, and in older children there may be the so-called brick-dust 
deposit in the urine. In these cases there may be a history of severe 
colicky attacks. In other cases the infant or child experiences pain 
on urination and cries piteously. Some older children will run about 
in pain and grasp the penis. In all such cases the diapers should be 
examined for concretions. Failing to find these, the urethra is care- 
fully explored. 

In several cases I have found an oval calculus of the size of a 
rice-seed, imbedded in the canal of the penile portion of the urethra. 
These cases have attacks of pain extending over months, probably 
caused by the passage of the calculi from the kidney through the 
ureter, the bladder, and urethra. The calculi are easily extracted 
with long-bladed forceps. In one of my cases of hematuria, in a 
boy three years of age, there were several attacks lasting for days, 
but no distinct history of pain. The urine contained blood coloring- 
matter, some blood-cells, and a few hyaline casts. The diagnosis 
was obscure until a few small calculi were found in the urine. Uro- 
tropin given in small doses caused a cessation of symptoms. 

Acute Nephritis. — A. Acute Parenchymatous Nephritis or Acute 
Exudative Nephritis (Delafield) ; Tubular or Glomerular Ne- 
phritis. B. Acute Diffuse Nephritis or the Acute Productive Ne- 
phritis (Delafield). — Etiology. — The etiology of both forms of 
acute nephritis is the same. 

There is scarcely an acute infectious febrile disease which may 
not give rise to acute nephritis. It complicates or follows scarlet 
fever, measles, influenza, diphtheria, infectious angina, pneumonia, 
rheumatism, typhoid fever, sepsis of all kinds, variola, parotitis, 
malaria, and congenital syphilis. The frequency in scarlet fever of 
the oedematous forms with anasarca has led to the belief that this 
disease was most often complicated by nephritis. If the parenchy- 
matous form is included, the condition will be found to be very fre- 
quent in other infectious diseases, but it is often unrecognized. 

The essential causes of acute nephritis are micro-organisms or 
their toxins. Thus in the various diseases, the Diplococcus pneu- 
moniae, the typhoid bacillus, streptococci of various kinds, staphylo- 
cocci, and the Bacillus pyocyaneus, have among other bacteria been 



DISEASES OF THE KIDNEY. Ill 

found in the kidney. On the other hand, in diseases such as diph- 
theria, the toxins of the bacteria are the cause of the parenchymatous 
or diffuse nephritis (Fiirbringer, Roux, Councilman ). If the toxin- 
are formed in the body, the infections are said to be autochthon or 
endogenous. The irritating toxin may be introduced from without. 
as in chloroform or ether narcosis, and the ingestion of drugs (eetoge- 
nous). The role played by cold as a causative factor is still a matter 
of speculation. Its mode of action, whether reflex, through the 
circulation, or by causing changes in the blood, is still obscure. 

Morbid Anatomy. — Acute Parenchymatous or Exudative Nephri- 
tis (Delafield). — This is an acute inflammation of the kidney, in 
which the principal changes occur in the epithelium of the tubules 
and Malpighian tufts. The kidneys are larger than normal, and 
succulent. The capsule can be stripped from the surface, whieh i- 
red, grayish, and punctate in spots. All the changes are most 
marked in the cortex of the kidney. Evidences of inflammation are 
found in the tubes, stroma, and glomeruli. The epithelium of the 
tubes is flattened, granular, and fatty, or in a condition of coagulation- 
necrosis. The lumen of the tubules may be empty or may be filled 
with desquamated epithelium or with coagulated masses (casts) of a 
hyaline character. Delafield describes the tubes, in severe cases, as 
filled with leucocytes and blood-cells. The tubes may be uniformly 
dilated. 

The changes in the glomeruli may be so slight as to be scarcely 
noticeable. The cavities of the capsules sometimes contain coagu- 
lated matter and red and white blood-cells (Delafield). In marked 
cases there are desquamation of capsular epithelium and increase of 
nuclei. The swelling and proliferation of cells sometimes change the 
appearance of the tuft so that the outlines of the individual capillaries 
are lost. The stroma is infiltrated with serum, and in severe cases 
there are in the cortex small collections of white blood-cells (pus). 

Acute Diffuse Nephritis. — The changes in acute diffuse nephritis. 
or the acute productive nephritis of Delafield, are more serious and 
permanent. According to Delafield, the kidneys are large, and ai 
first smooth and later rough. The cortex may be mottled yellow 
and red; the pyramids are red. 

In this form of nephritis there are the changes found in exudative 
nephritis, and also a growth of connective (issue in the stroma and 
an increase of the capsule cells of the Malpighian bodies. These 
changes involve symmetrica] strips of the cortex, which follow the 
lines oi' the arteries (Delafield). The Malpighian bodies show an 
enormous growth of capsule cells with compression oi the tufts. If 
the nephritis is acute, the interstitial tissue is augmented with newly 
formed cells and basement substance. There is a new growth 



778 DISEASES OF EIDXEYS AXD UROGENITAL TRACT. 

connective tissue between the tubules ; the walls of the arteries are 
thickened. In the capsule of the Malpighian tuft there is a growth 
of cells which compress the tuft of vessels. These and the vessels 
are in turn converted into small balls of fibrous tissue (Delafield). 
In addition there may. in the acute forms of nephritis, be hemor- 
rhages throughout the kidney substance. 

Symptoms. — In the forms of parenchymatous nephritis which 
complicate the febrile infectious diseases, influenza, pertussis, angina, 
and gastro-enteritis, either the symptoms of the primary disease 
mask those due to the kidney lesion or the nephritis may be so mild 
as to give no symptoms. Thus in the parenchymatous nephritis 
which complicates or follows influenza, there are after the attack has 
passed no symptoms referable to the kidneys, yet on examination the 
urine shows a trace of albumin, hyaline and a few epithelial casts, 
and an occasional red blood-cell. In these cases there is no oedema 
of the tissues, no headache, and the children are apparently well 
except for the changes in the urine. These may at first be quite 
marked. After a few months the albumin may only appear occa- 
sionally ; the casts and blood disappear for weeks and then reappear. 
For weeks or months the children may have no constitutional 
symptoms. 

In the parenchymatous nephritis, which is seen in severe forms 
of gastro-enteritis and dysentery, the signs in the urine of marked 
nephritis are albumin, casts of all kinds, and blood-cells (Parrot, 
Fischl, Czerny, Koplik, and Morse). Although Czerny traces a cer- 
tain form of dyspnoea to the influence of uraemia in these cases, no 
distinct set of symptoms due to the kidney can yet be formulated. 
It is true that there are terminal anasarca, suppression of urine, and 
vomiting, but the presence of all these may be explained by the 
severity of the intestinal lesions and toxaemia. 

Chaxges ix the Urixe. — In all the diseases above mentioned, 
the parenchymatous nephritis may in infants and children be evinced 
by diminution of the quantity of urine, or the presence of a trace of 
albumin, or a few hyaline or epithelial casts and blood-cells. The 
quantity of urine may. however, be normal. In other cases, the 
albumin is more marked and the casts much more numerous. Renal 
epithelium is also present. Leucocytes are rare. 

In the diffuse or productive form of nephritis in infants and 
children, the symptoms are marked. In some forms of nephritis 
complicating scarlet fever the lesion never advances beyond the 
parenchymatous stage, and at that period the symptoms are either 
not present or not noticeable. If the nephritis is more marked, how- 
ever, it is noticed at the end of the third week that the patient is 
somewhat pale, that the face is a little swollen, especially about the 
eyes, and that there is very slight oedema of the general surface. 



DISEASES OF THE KIDNEY. 779 

In these cases it is possible at the end of the period of eruption 
to find a slight trace of albumin in the urine and a few hyaline and 
epithelial casts. With the onset of the anasarca the albumin in- 
creases in quantity, the casts in number, and a few blood-cells are 
found. The quantity of urine is diminished, but in the mild forms 
not markedly so. A boy of six years may pass half the normal quan- 
tity. There is no headache, and only a few obscure pains in the 
joints. There is occasionally slight pain in the region of the kidney. 
The temperature is normal or may at intervals of several days rise 
a degree or a degree and half above the normal. The nephritis is 
probably of the mild diffuse type. In three weeks the moderate 
anasarca disappears, the anaemia improves, and the urine becomes 
normal. 

In the more severe cases there is a rise of one or two degrees 
in temperature, and the patients have marked general anasarca. If 
old enough, they complain of headache, they vomit, and show marked 
decrease in the number of respirations and pulse, the irregularity 
of pulse being of a purely ursemic character. In some cases there 
are effusion into the chest (hydrothorax) and abdominal ascites. 

The quantity of urine is much diminished, there being only one 
or two ounces in twenty-four hours. The specific gravity is high ; 
the urine contains blood, leucocytes, and casts (hyaline, granular, 
and epithelial), with blood cells. Under treatment, the vomiting, 
headache, and anasarca subside, the quantity of urine increases, the 
number of casts and blood-cells diminishes, and the patient makes 
a good recovery. In other cases the initial anasarca becomes more 
marked, there being considerable oedema of the whole surface; the 
urine is entirely suppressed; the vomiting and headache increase; 
convulsions set in ; there are several attacks of eclampsia ; the patient 
becomes comatose, and may die of uraemia, or after one or two attacks 
of eclampsia, the symptoms may abate and recovery take place. 

There is a very fatal form of diffuse nephritis which occurs on 
the fourth or fifth day of malignant scarlet fever. On the third day. 
at the height of the eruption, the patient passes into a delirious, semi- 
conscious state. The quantity of urine is much diminished : its 
specific gravity is high ; casts of all kinds and blood are present. The 
urine may finally be totally suppressed. There is no oedema of the 
surface. Coma and convulsions set in. The patient succumbs 10 
the intense general toxaemia and to its effect on the kidneys. In 
these cases the kidney symptoms cannot be separated from those 
caused by the general intoxication. 

Individual Symptoms.- Vomiting. — The vomiting in scarla- 
tinal nephritis is rarely distressing, and subsides in a short time. It 
is not a constant symptom, nor is it of serious import. 



780 DISEASES OF KIDNEYS AND UROGENITAL TRACT. 

Headache. — The headache is not a very marked symptom in 
children. 

(Edema. — (Edema is present in a large proportion of cases, and 
is marked in the severe ones. It may occur with hydrothorax, 
ascites, and hydropericardinm. It may affect only the face, or the 
lower extremities alone. It may be so intense as to cause bursting 
of the skin and the escape of serum through the fissures. It may 
affect one half the body more than the other (Henoch). Under all 
these conditions, the outlook is serious. 

Pulse. — The pulse is sometimes inordinately slow. It may be 
more rapid than normal, and may show marked irregularity. 

Heart. — The heart may, as was pointed out by Henoch and 
Friedlander, be the seat of hypertrophy and dilatation. There may 
be complicating endopericarditis. 

Lungs. — The lungs may be the seat of pneumonia, or oedema of 
the lungs may suddenly develop. There may be complicating 
pleuritis. 

Constipation. — There may be constipation or more or less 
diarrhoea. 

Temperature. — There are cases in which the temperature is 
normal or subnormal during the whole course of the disease. In the 
cases in which there are sudden eclamptic seizures, the temperature 
may mount to 104° F. (40° C.) during the attacks. On account 
of the rupture of a bloodvessel in the brain during the eclamptic 
seizures there is in many cases, after the subsidence of the uraemic 
symptoms, aphasia, or hemiplegia of a more or less permanent nature. 

Fainting Spells. — Patients with nephritis succeeding scarlet fever 
develop fainting spells with cyanosis, gallop-rhythm, and all degrees 
of cardiac weakness. It is difficult in such cases to know whether 
to attribute these symptoms to the nephritis or to myocarditis which 
is the result of the scarlet fever. 

Urine. — The general characteristic features of the urine in acute 
diffuse nephritis of scarlet fever have been given. Suppression may 
take place suddenly. The urine may not have contained coagulable 
albumin or casts, and the quantity may have been normal. The 
common notion that uraemia or eclampsia can supervene only if the 
quantity of urine is diminished, is erroneous. Even if the quantity 
is above the normal and the urine contains little albumin and few 
casts, eclampsia may supervene with fatal results. An increase in 
the quantity of urine above that of the normal is an unfavorable 
symptom unless temporary and accounted for by the treatment. 
The quantity of urea passed is always the crucial test. There are 
cases in which blood appears in the urine and in which there is true 
hemoglobinuria, which may give rise to irritation of the kidney. In 



DISEASES OE THE KIDNEY. 781 

other words, the hemoglobinuria is primary, the nephritis secon- 
dary. The quantity of albumin in the urine varies greatly; it may 
only amount to a trace or be sufficient to cause the urine to become 
solid when boiled. 

Primary Forms of Acute Nephritis. — The question has arisen : Can 
nephritis be primary? If nephritis is the result of some form of 
infection, it cannot be primary. Henoch, Heubner, Bouchut, Bartels, 
Loos, and Holt have published cases in nurslings, the origin of which 
could not be traced. These occurred in infants from five weeks to 
one and a half years of age, who suddenly developed marked anasarca 
and vomiting, with suppression of urine. Some of the cases had a 
febrile movement of a remittent type. The majority of them were 
fatal. Their exact nature is still unknown. Uhlenbrock has re- 
cently collated all the cases in the literature, but has thrown no light 
on the subject. On autopsy, a few cases have shown a parenchy- 
matous nephritis. 

Course. — The majority of cases of parenchymatous or exudative 
nephritis recover. The prognosis of the diffuse or productive form 
is more serious, but in exceptionally mild cases recovery may take 
place. Others cases make an apparent recovery. After the symp- 
toms of oedema and anasarca have disappeared, anaemia remains. 
The albumin in the urine may disappear and reappear. In six 
months or a year, general anasarca may set in with all the symptoms 
of an acute exacerbation of the disease. The patient may eventually 
recover from the attack, but as a rule others of the same kind follow. 
and the condition of chronic nephritis results. 

Duration. — The acute forms of parenchymatous or diffuse neph- 
ritis last from two to six weeks. The parenchymatous forms are 
sometimes evanescent, the marked symptoms lasting only a week. 

Chronic Diffuse Nephritis.. — (a) Chronic Productive Ncpliritis, {b) 
Chronic Nephritis without Exudation (Deeafield) . — The forms of 
chronic diffuse nephritis are the same in childhood as in adult life. 
They usually occur late in childhood. Thus one case of chronic 
diffuse nephritis in a girl of fourteen years of age dated from an 
attack of scarlet fever at the age of eight years. At autopsy there 
was found a diffuse nephritis of the productive variety (large white 
kidney). In another case, a boy of twelve 1 years, with diffuse neph- 
ritis of the non-productive variety (small cirrhotic kidney), had had 
an attack of scarlet fever at the age oi' five years, lie had no 
anasarca in the course of the nephritis. Active symptoms of head- 
ache and vomiting appeared a year and a half before his death. The 
quantity o( urine was above the normal and there were a few hyaline 
casts. At autopsy a small kidney was found. Thns there may in 
children be two forms <^( chronic nephritis following scarlel fever 



782 DISEASES OF KIDXEYS AXD UEOGENITAL TEACT. 

or any other infectious disease. Adults present symptoms referable 
to the eye, such as neuroretinitis, which I have not met with in chil- 
dren, and which must be exceedingly rare in them. Neither have I seen 
in children the emphysema met in adults. The heart may be hyper- 
trophied and dilated in children as in the adult. They may have 
endocarditis and pericarditis with pleurisy. 

Treatment. — The forms of parenchymatous or exudative nephritis 
which so frequently occur as accompaniments of the acute febrile dis- 
orders, pneumonia, typhoid fever, influenza, etc., need little or no 
treatment. There are no symptoms referable to the kidney. Neph- 
ritis accompanying acute gastro-enteritis is best treated by remedies 
directed toward the primary affection. The quantity of urine is 
sometimes diminished. It contains casts of all kinds. Rectal ene- 
mata of saline solution at a temperature of 108° F. (42.2° C.) are 
then of great utility, not only in supplying fluid to a depleted circu- 
lation, but also in stimulating the circulation and therefore the kidney 
secretion. Drugs which might still further compromise the condi- 
tion of the kidney should not be given for the intestinal affection. 
Hot baths are of great utility, 105° F. (40.5° C). 

In the partial or complete suppression of urine seen in the first 
few days of the malignant forms of scarlet fever, more active treat- 
ment is required. When the temperature is high, the pulse rapid 
and weak, the patient unconscious or delirious, and the urine dimin- 
ished or suppressed, I administer high and large rectal enemata of 
water at a temperature of 108° to 110° F. (42.2° to 43.3° C), as 
recommended by Kemp. These should not be given to children with 
a double-current tube, but simply as enemata. About a quart of 
saline solution is thrown into the rectum at very low pressure. A 
fountain bag syringe is utilized for this purpose. These enemata 
stimulate the heart and circulation and supply the system with 
normal fluid. To stimulate the skin, the warm baths are preferable 
to cold ones. Patients are frequently much depressed by cold packs 
or baths given to reduce the temperature. The temperature of the 
bath should be at least 105° F. (40.5° C), and the patient allowed to 
remain in it five or ten minutes, according to the state of the pulse. 

In acute cases the anasarca will, as a rule, take care of itself. If 
it is extreme, Senator advises the administration of diuretics in acute 
as well as chronic nephritis. Some authors recommend diuretin and 
digitalis in form of infusion, a drachm being combined with an 
agreeable alkali, such as citrate of potassium. The pulse should be 
watched. If it is low, the digitalis is suspended. I do not utilize 
whiskey or alcohol in these cases. In acute diffuse nephritis and 
in productive nephritis similar to that of scarlet fever, the ursemic 
symptoms, the oedema, and the kidneys are treated. Vomiting is a 



DISEASES OF THE KIDNEY. 783 

ursemic symptom which is prominent at first. If the patient vomits 
everything ingested, no food should be given by month. The patient 
is nourished by rectum by means of somatose or nutritive enemata. 

The headache needs little treatment. Bromide and a small done 
of chloral or trional are given for restlessness at night. In the forms 
of nephritis, generally subacute, in which there are oedema amount- 
ing to anasarca, and diminution of urine, baths and diuretics are 
beneficial. The anasarca is sometimes scarcely noticeable, and the 
quantity of urine little diminished. There are usually a few hya- 
line and epithelial casts, and also blood-casts. The patient is kept 
in bed and put on a milk diet. The bowels are kept open by means 
of Vichy water given in liberal quantities, or by Carlsbad salts. A 
child between four and six years of age should take half a drachm 
of the salts once a day. Some mild diuretic, such as citrate or ace- 
tate of potassium, is given. The pulse may be 80 or 90, and digi- 
talis is therefore not given. Under this mild therapy the anasarca 
subsides, the albumin diminishes, and the urea and quantity of urine 
increase. Milk also tends to increase the quantity of urine. A 
bath at 104°-105° F. (40° C.) is given every day or every second 
day according to the indications. The diaphoretic effects of vapor 
baths are less marked. 

In some of the severer cases the urine is greatly diminished, the 
anasarca extreme, the pulse and respirations are increased, and the 
temperature may be elevated. The anasarca is then treated by a 
daily warm bath, in which the patient remains for five minutes, and 
is then wrapped in a warm dry blanket to promote diaphoresis. A 
warm rectal enema at the temperature above mentioned is given twice 
daily. The kidneys are stimulated by means of digitalis and ace- 
tate, citrate, or tartrate of potassium. 

The digitalis is given in form of the infusion, 5ss-3j with 3 to 8 
grains of the potassium salt, three or four times daily. The pulse 
is closely watched and not allowed to fall too low. The bowels are 
kept open by the daily administration of cathartics. If, as fre- 
quently happens, the heart becomes weak, sparteine or liq. ammonise 
acetatis and nitroglycerin may also be given. I do not administer 
preparations of musk or camphor in nephritis. Convulsions are 
best controlled by means of chloroform. Warm baths and high warm 
enemata are also useful. Bromide and chloral are also given by 
rectum, as in ordinary eclampsia. 

In convalescence the question arises. When shall diuretics be 
discontinued? As soon as the quantity oi' urine is above the normal, 
they are of no further value. The baths and enemata are continued 
as long as there is the least oedema oi' the surface. Warm enemata 
should not bo continued after the urine has increased to the normal 



784 DISEASES OF KIDNEYS AND UROGENITAL TEACT. 

amount. Ordinary enemata are then given for the purpose of aid- 
ing the cathartics in keeping the bowels open and clear of fa?cal 
accumulations. 

Rest in bed should be continued until there is no palpable albu- 
min reaction. Meat and vegetables are then added to the diet list. 
If anaemia is present, a readily assimilable form of iron, such as the 
peptonate, is given. Casts will appear in the urine far into conva- 
lescence. The patients may, however, be allowed to be up if they 
bear the change well. A too protracted stay in bed is sometimes 
exhausting in summer. If symptoms of anasarca and other signs 
of nephritis recur, the treatment is the same as in primary acute 
attacks. The treatment of chronic nephritis in children does not 
differ from that followed in the adult. I have recently subjected 
two children who suffered from the chronic diffuse form of nephritis 
following scarlet fever, accompanied by recurrent attacks of anasarca 
extending over years, to EdebohFs operation of splitting or extirpa- 
tion of the kidney capsule. Both cases were much benefited by the 
operation. One case was free from symptoms for fully a year. If 
we can improve these cases to this extent, the operation is certainly 
indicated, even if the operation is powerless to restore the kidney to 
the normal. 

New Growths of the Kidney. 

Thirty-eight per cent, of all the reported cases of kidney tumors 
occurred in children (Doderlein, Lewi). The following growths are 
here considered: 1. Cysts of the kidney; 2. Tuberculosis of the 
kidney ; 3. Carcinoma of the kidney ; -4, Sarcoma of the kidney. 

Cysts of the Kidney. — Cysts of the kidney in children are usually 
of congenital origin. They are formed in the second half of intra- 
uterine life. They are bilateral, only 1 in 60 being unilateral 
(Lejars). The kidney is made up of greater and smaller cysts. 
The cystic formations may be present to the entire exclusion of 
kidney tissue. The cysts may attain the size of a child's head and 
seriously obstruct delivery. They are of anatomical interest only, 
since infants with such cysts present other abnormalities and die 
soon after birth. 

Hydronephrosis. — Hydronephrosis is either congenital or ac- 
quired. If acquired, it occurs late in childhood. The congenital 
form is due to stenosis in some part of the urinary tract. Hydro- 
nephrosis is as a rule unilateral. If it occurs after birth, it may 
be due to obstruction by calculi or to uric acid infarction of the kid- 
ney. The healthy kidney is physiologically enlarged. The acquired 
form is due to obstruction by calculi or to tumors pressing on the 
ureters. At first the pelvis of the kidney, then its tissue is en- 



PLATE XXXV 




Sarcoma of the Kidney. Child six years of age 
Irregular contour of the abdominal tumor. 



DISEASES OF TEE KIDNEY. 785 

eroached upon in the gradual dilatation. Finally the shape of the 
kidney is lost. There is a large fluctuating tumor which in ay or 
may not be painful. When punctured, a fluid of low specific gravity 
is withdrawn which contains albumin, epithelium, urea, uric acid. 
In some cases there occurs what is known as intermittent hydro- 
nephrosis. The contents of the tumor are emptied spontaneously, 
but reaccumulate. The diagnosis rests on the presence of a fluctuat- 
ing tumor containing a fluid, with urine constituents. Cystoscopy 
may in some cases reveal obstruction of the ureters. 

Cysts must anatomically be differentiated from the condition of 
hydronephrosis. Cysts are new growths (Senator) ; in that respect 
they differ from the cystic condition of hydronephrosis. It is not 
possible clinically to differentiate congenital cysts of the kidney from 
congenital hydronephrosis. 

Sarcoma of the Kidney. — Sarcoma of the kidney occurs in chil- 
dren as a primary growth. In the statistics of Rosenstein and 
Senator two-thirds of the cases occur before the tenth year. It is 
more frequent in females. The left kidney is more commonly 
affected. Sarcoma occurs in the newly born infant. The presence 
of muscle, bone, and cartilage tissue in these growths supports the 
theory of their congenital origin (Jacobi). The anatomical nature 
of the growth varies widely. It may be round-celled or spindle- 
celled sarcoma, a fibro-sarcoma, myo-sarcoma, angio-sarcoma, mela- 
notic sarcoma, or adeno-sarcoma. There may be metastases. The 
tumors sometimes attain a weight of fifteen pounds. 

Symptoms. — The symptoms do not differ materially from those of 
carcinoma of the kidney, nor is sarcoma of slower growth. In many 
cases the pain, hematuria, and tumor follow a traumatism. Hema- 
turia is not, as in carcinoma of the kidney, a constant symptom. I 
have seen cases of both carcinoma and sarcoma of the kidney in young 
children without hematuria or growth elements in the urine. Ascites 
is present in more than one-half the cases (Lewi). 

Diagnosis. — A malignant growth in a child may be surmised to 
be a sarcoma, since those growths are more frequent in children than 
carcinomata. Swelling of the lymph-nodes may be present in sar- 
coma as well as in carcinoma. Histological elements in the urine 
are rare. Von Jaksch has mentioned the presence of small round 
cells (sarcoma cells), but their significance is not as yet determined. 
Puncture for diagnostic purposes is dangerous, and it" performed at 
all should be done posteriorly in the lumbar region (extraperito- 
neal). In sarcoma of the kidney, as in all growl lis of that organ, 
the colon is pushed in front o( the growth (Plato XXXV.). 

Carcinoma of the Kidney. — Of 449 cases o( carcinoma of the 
kidney ("Rohrer, Ebstein, Lachman), 157, or almost 35 per cent.. 

50 



786 



DISEASES OF KIDNEYS AND UROGENITAL TRACT. 



occurred in children under the tenth year. Monti tabulated 50 
cases, and found that more than 50 per cent, occurred in children 
under the age of two years. The youngest patient was twelve months 
of age. It is more frequent in males. As a rule the right kidney 
is affected. In children, the growth is apt to attain great size. 
Guillet found that the average weight was eight and one-half pounds. 
By reason of the great weight of the growth, the kidney may sink 
from its normal position and lie transversely across the vertebral 
column. The growth is a primary one. The medullary carcinoma 



Fig. 17 



Fig. 179. 




Enlargement 



Anterior palpable tumor beneath the 
liver. 



of the kidney. 

Posterior area of flatness in the 
lumbar region, giving a palpable tumor 
between the border of the ribs and the 
crest of the ilium. 



is the prevailing type; the scirrhous is next in order of frequency. 
The disease may be secondary to carcinoma of the suprarenal cap- 
sule or of the retroperitoneal glands. The liver, the lungs, and the 
inguinal lymph-nodes may be secondarily involved. 

Symptoms. — The chief symptoms are pain, hsematuria, cachexia, 
and enlargement of the kidney. Guillet found that hsematuria was 
the first symptom in one-half the cases. The quantity of blood 
passed may be very small, or so great as to amount to a dangerous 
hemorrhage. The urine may be red or chocolate colored, and may 



DISEASES OF THE KIDNEY. 787 

contain clots of blood or casts of the ureters. Frequent micturition 
is sometimes an early symptom. In other cases there is no haema- 
turia, the cachexia, emaciation, and tumor being the first symptoms. 
In younger children the hematuria is frequently absent. Thekidi 
is in these cases protected from traumatism. The tumor is some- 
times so great as to cause displacement of the organs. In Fiir- 
bringer's case the heart was displaced to a situation beneath the 
clavicle. The abdomen is distended, and the colon is pushed in 
front of the growth and is indicated by a tympanitic area at one side 
of the median line of the tumor. On the right side, the tumor appears 
beneath the liver, and in narcosis can be felt in that situation as a 
distinct mass. The tumor has an uneven surface. The urine may, 
in addition to blood, contain histological elements of the growth. 
This does not occur so frequently in carcinoma of the kidney as in 
tuberculosis of that organ. 

Duration. — The progress of the growth is much more rapid in 
children than in adults. In the former subjects the duration of the 
disease is from ten weeks to fourteen months (Roberts). 

Diagnosis. — In children, while the diagnosis of a morbid growth 
of the kidney can be made, it is not possible to differentiate between 
the symptoms of carcinoma and those of sarcoma. It cannot be 
determined, from the symptoms, whether the growth is a simple car- 
cinoma, an adeno-carcinoma, or an adeno-sarcoma. The symptoms 
of a malignant growth of the kidney are pain, hematuria, tumor. 
and cachexia. A cyst of the kidney may be confounded with a 
malignant growth. Cysts are congenital, and as a rule bilateral. 
This is also the case in hydronephrosis. In the latter condition extra- 
peritoneal puncture of the tumor may give a fluid with urine con- 
stituents. In carcinoma of the kidney, puncture for diagnostic pur- 
poses is not devoid of danger. 

Tuberculosis of the Kidney. — Tuberculosis of the kidney is rarely 
if ever primary. Senator asserts that it never occurs as a primary 
lesion. There are pathologically two forms — the miliary and the 
cheesy. The miliary form is more frequent in children, the cheesy 
in later life. In the miliary form, the kidney tissue is the seat of 
an eruption of miliary tubercles. In the cheesy form, tuberculous 
nodules may entirely replace the substance of the organ. The 
cheesy form is as a rule secondary to tuberculosis of the genitals the 
epididymis in boys and the tubes in girls. The symptoms do not 
differ materially from those of the same condition in adults. In 
the miliary form there are no symptoms. In the cheesy \;i; 
there arc dysnria, strangury, vesica] tension, pain in the region of 
the kidney, emaciation, and fever. The urine contains albumin, 
blood, epithelium, and pus cells, and is acid in reaction. Tubercle 
bacilli are sometimes found. 



788 DISEASES OF KIDNEYS AND UROGENITAL TRACT. 

Diagnosis. — The diagnosis rests on the presence of tubercle bacilli 
in the urine, a tuberculin reaction, an enlarged palpable kidney, 
hematuria, and tuberculosis of other organs — the genitals or the 
lungs. 

Treatment of New Growths of the Kidney. — The treatment of 
new growths of the kidney is within the province of the surgeon. 
The congenital cysts are of scientific interest only. If there is rea- 
son to believe that there is congenital hydronephrosis which is uni- 
lateral only, surgical interference is indicated. Sarcomata and car- 
cinomata should be treated surgically if there is reason to believe 
that there are no metastases in the liver or elsewhere. Tuberculosis 
of the kidney is treated more from a general standpoint. If there 
is tuberculosis elsewhere, palliative treatment alone must suffice. 
Isolated tuberculosis of one kidney is a rare condition which necessi- 
tates extirpation of the organ. If it is impossible to determine the 
proper treatment, an exploratory operation is indicated. 

Perinephritis and Paranephritis. — This condition is rare in in- 
fancy and childhood. It is not always possible to determine the 
cause. If such is the case, the disease is called primary. As a rule, 
it is secondary to traumatism in the lumbar region, to pyelitis, or to 
pyelonephritis. It may occur in septicopyemic processes, and I 
have seen it follow the infectious diseases, notably scarlet fever. Of 
166 cases collected by IsTieden, only 26 occurred in children. One 
case occurred in an infant five weeks old. Gibney's cases ranged 
from one and a half to ten years of age. The condition is more 
common on the left side. The pus may burrow behind the liver or 
spleen, or find its way downward, forming a mass simulating a cold 
abscess or a perityphlitic abscess. It may perforate into the pelvis 
of the kidney, the intestine, peritoneum, vagina, or diaphragm, or 
may pass along the ileopsoas muscle, and find its way to the hip, 
and thus appear externally. The kidney may be involved because 
of its contiguity to the seat of the process. Pleuritic metastases and 
amyloid degeneration may finally result. 

Symptoms. — The symptoms are usually obscure. The fever is 
intermittent or remittent. Young children do not as a rule complain 
of pain. The first intimation of the nature of the disease is the 
appearance of a swelling in the lumbar region. On bimanual palpa- 
tion a tumor which is fixed, tense, and does not move with respira- 
tion, is felt deep under the liver, in the region of the caecum and 
ascending colon on the right side, or underneath the spleen on the 
left. Gibney has described these cases and shown how they may be 
easily mistaken for cases of cold abscess. The thigh of the affected 
side is held in a condition of semiflexion. 

Treatment. — The treatment is surgical. 



DISEASES OF TEE KIDNEY. 7 '89 

Enuresis Nocturna and Diurna. — This is a functional neurosis of 
the bladder in which the urine is passed involuntarily, and. as a 
rule, at night during the first hours of sleep. It may, however, be 
passed at any time during the night. Some patients have at times 
no control over the bladder during the day (diurna). Some have 
enuresis every other night or only once or twice a week, and others 
suffer from the affection over night. Cases of enuresis should be 
differentiated from those in which there is a complete paresis of the 
sphincter vesicas. In the latter case the urine simply flows away. 
These are cases of disease or anomaly of the cord (spina bifida). In 
enuresis the children may in other respects be in good health. There 
is frequently a nervous condition. In some cases there is lithiasis 
or stone in the bladder; in others the etiological factor is Oxyuris 
vermicularis, obstipation, tumor of the bladder, or vulvovaginitis. 
Cystitis and adenoids have been regarded as causal. In the majority 
of cases no cause can be found. The condition follows the exan- 
themata. In boys it usually disappears toward the sixteenth year. 
I have seen it persist in girls into adult life. Its treatment becomes 
a very serious problem. 

Diagnosis. — The diagnosis is not difficult. The urine should be 
carefully examined for evidences of lithiasis, cystitis, glycosuria, 
nephritis, and nematodes, and the bladder for stone. The diagnosis 
is not made in infants and very young children. In the latter the 
enuresis is often only apparent. They do not know how to indicate 
their wants. 

Treatment. — The urine should be passed before retiring. The 
patients should take little liquid at the evening meal. The foot of 
the bed is raised so that the head is slightly lower than the pelvis. 
The drugs most utilized are ergot and atropine. The former is 
given in the fluid extract, minims x to xxx (0.6 to 2.0) t. i. d. Atro- 
pine is given before retiring in a solution (grain j to Jij ; 0.06 to 
30.), a drop for every year of the age (Watson). It is efficient in 
many cases, but in some children distinctly dangerous. I had one 
case in which I gave one-half the above dose. The child, five years 
of age, became slightly delirious and tried to walk out of a window. 
Many cases will improve, only to be subject to relapses. Marion 
Sims has shown that enuresis in young girls may be duo to an intol- 
erant and very small, contracted bladder. In such eases, he advises 
gradual dilatation of the bladder by injecting the organ with in- 
creasing quantities of an indifferent fluid. If treated in this way. 
the bladder will eventually retain urine. Most of the easis resist 
all methods of treat men). 



790 DISEASES OF KIDNEYS AND UEOGENITAL TRACT. 

DISEASES OF THE UROGENITAL TRACT. 

Vulvovaginitis {Urogenital Blennorrlioea). — The term vulvovagi- 
nitis, or, as it is now called, urogenital blennorrhoea, refers to a gon- 
orrlioeal inflammation of the genital tract in children. Before de- 
scribing the condition it is necessary to refer to catarrhal conditions 
which are not gonorrheal, and which are present in the normal state. 

Etiology. — Epstein has shown that in the newly born infant there 
is a physiological and normal discharge from the vagina. It is an 
adhesive, mucoid discharge containing epithelial cells and micro- 
organisms. A few days. after birth, this discharge assumes a puru- 
lent and, in icterus, an icteric hue. ~No leucocytes are found in the 
discharge. In two weeks it ceases and the parts appear normal. 
This form is not gonorrhoea! A second condition which I have noted 
in very young children is the result of uncleanliness, lithiasis, irrita- 
tion caused by Oxyuris vermicularis, or masturbation. The parts are 
reddened and eroded, and are bathed with an abnormal serous dis- 
charge. There may be a few erosions around the introitus. These 
cases recover with ordinary care and removal of the source of irri- 
tation. Pus is rarely secreted. 

A second group of cases occurring in young female children 
includes those of vulvovaginitis of the simple catarrhal type. These 
have a scanty or profuse purulent discharge from the vagina, vulva, 
and urethra, which presents clinically all the features of the specific 
gonorrheal group, but is not gonorrheal. The condition is not of 
infrequent occurrence. The urethral orifice is swollen and red. The 
hymen is also swollen and inflamed. The discharge is thin and 
milky, or greenish and viscid. Microscopically, it shows in the pus- 
cells bacteria and diplococci in groups, but these do not show either 
by culture or on staining the characteristics of the gonococci. The 
history of such discharges is singularly similar to that of the gonor- 
rheal form. Urination is painful, and the discharge persists even 
under careful treatment. In one case of this kind I have seen an 
inguinal bubo. The catarrh, like the gonorrheal form, affects the 
urethra, vulva, vagina, and cervix uteri. I am convinced that the 
discharge is infectious and communicable from one child to another. 
It may last for months and again recur. Its exact etiology is still 
unknown. Uncleanliness, infection from a vaginal discharge, maras- 
mus, the infectious diseases, or frail health may be the cause. 

Cases of urogenital blennorrhea have been described by Pott, 
van Dusch, Spaeth, Cahen-Brach, Epstein, and others. 

Occurrence. — This affection may occur in newly born infants (Ep- 
stein) or in older infants and children. Epidemics may occur in hos- 
pitals (Frankel). The avenue through which the disease is conveyed 



DISEASES OF TEE UROGENITAL TRACT. 



791 



is still unknown. It occurs in all walks of life. In some cases there 
is a history of the child's having slept with the mother. In others, 
there is no such history. I have sometimes obtained a history of 
an abnormal attempt at coitus between boys and girls, the boys 
having suffered at the time from gonorrhoea. Such cases are, how- 
ever, exceptional. The exciting cause is the gonococcus (Neisser) 
(Fig. 180). This micro-organism has been found in the discharges 
of all these cases, and cultivated (Koplik, Heiman, Wollstein). 

Symptoms. — There is a thick, viscid, purulent, greenish or yel- 
lowish discharge from the vagina, which bathes the parts and dries 
in crusts on the labia. The opening of the urethra is reddened and 
swollen. There is a discharge from the urethra. Micturition is 
painful. In some cases there are slight swellings of the inguinal 

Fig. 180. 




Gonococci in vaginal discharge. Cover-glass spread. Photomicrograph, x 1000. 



lymph-nodes. If the speculum which is used for the male urethra 
is introduced into the vagina (Tuttle's urethral speculum V it is seen 
that the purulent discharge is present in the folds of the mucous 
membrane of the vagina. The cervix uteri also contains a drop of 
pus. Thus the whole genital tract is involved. Some children com- 
plain of pain over the lower part of the abdomen. On examination. 
this is found to be pelvic, and is probably due to inflammatory n ac- 
tion of the tissues about the uterus and vagina. 

Complications and Course.- -The course of the disease is quite 
tedious, and may occupy eight weeks, three months, or more. The 
discharge may abate, only to return in its original severity. 

Peritonitis has in rare castas been reported as a complication oi 
this form o( vulvovaginitis. It may prove fatal. 1 have nut two 



792 DISEASES OF KIDNEYS AND UROGENITAL TRACT. 

cases. Hunner and Harris recently reported a fatal case in a girl 
ten years of age. They collected 5 other cases from the literature 
occurring in children. Pelvic peritonitis occurred in 2 of my cases 
with the usual signs of pain and fever. Both cases made a good 
recovery. 

Hartley and the writer have reported cases of arthritis complicat- 
ing vulvovaginitis in children. My cases occurred in the first and 
second weeks of the disease. In one case, only one joint was affected ; 
in another, two. Both recovered without suppuration. 

Gonorrhoeal conjunctivitis may result from careless infection of 
the eyes. I have had only 2 cases in which the patients complained 
of precordial pain. In neither were there active symptoms of endo- 
pericarditis, but there is no reason why it might not occur in children, 
as in adults. 

Sanger at one time traced a connection between sterility in later 
life and attacks of this disease in childhood. 

Treatment. — Prophylaxis is of great importance. A child affected 
with the disease should not be allowed to sleep with other children. 
The toilet appliances should not be used by other children. The 
parents should be carefully enlightened concerning the infectious 
nature of the affection and the great danger to the eyesight should 
infection of the eyes occur. The hands of the patient should be kept 
scrupulously clean. In institutions the patients should be strictly 
isolated. The vulva should be kept covered with a pad of absorbent 
gauze, and a diaper should be worn over this to prevent the dis- 
charge from soiling the clothes. In the acute stage, the vagina should 
be irrigated with a glass catheter or a Skene urethral catheter twice 
daily. The solution should be at a temperature of 108° P. (42.2° 
C). The irrigating solutions should be either a 2 per cent, solution 
of acetate of aluminum or a 1 : 2000 or a 1 : 500 solution of nitrate 
of silver. If the silver or aluminum solution is irritating a simple 
saturated solution of boric acid may be used. 

I have found a 25 per cent, solution of argyrol quite effective in 
diminishing the severity of the discharge. The vagina is first irri- 
gated with boracic acid and then with the solution of argyrol. In the 
subacute stage the vagina is painted every other day with a 5 or 10 
per cent, solution of nitrate of silver. A Tuttle urethral speculum 
is used for the purpose. If the child is intractable, it is impossible 
to do this without the use of an anaesthetic, which, however, seems 
scarcely justifiable. I have cured these cases with rest in bed and 
irrigations. I have tried the bougie treatment and the protargol and 
permanganate of potassium irrigations, but have found the treatment 
above described preferable. 



DISEASES OF TEE UROGENITAL TRACT. 793 

Urethritis in Male Children. — Simple urethritis of the anterior 

portion of the urethra occurs in infants and young children. It is 
caused either by unnatural interference with the parts or infection. 
It is not gonorrhoea!. The meatus is slightly red or the parts are 
agglutinated with dried pus. On pressure, a drop of pus exudes 
from the urethra. There is ardor urinse, due to a slight fissuration 
of the meatus. The affection is easily cured by attention to clean- 
liness. An alkali, such as citrate of potassium, is given in very small 
doses, to alleviate the ardor urinse. 

Gonorrhoea occurs in male infants and boys, and is the result of 
direct infection. The symptoms are much the same as in adults, 
except that, as a rule, there are no complications. Balanoposthitis 
and lymphadenitis may occur, also epididymitis, and rarely orchitis. 
Bokai reports cases of stricture. 

Cystitis, Pyelitis, and Pyelonephritis. — This affection, which is 
peculiar to infants and children, was first called coli-cystitis by 
Escherich, in view of the bacterial causation of the disease. The 
question of nomenclature is complex in view of the fact that Amer- 
ican (Holt) and English authorities designate this affection by the 
term pyelitis, whereas the Germans speak of cystitis. The question 
is one of origin of the disease and from my own experience I think 
it but proper to call the disease cystitis, inasmuch as it seems to me 
most of the cases originate from local infection in the bladder. The 
infection may then travel up the ureters and involve the pelvis of 
the kidney and finally the kidney itself may become involved in the 
suppurative process and there results a pyelo-nephritis. There are. 
however, certain rare cases which cannot be accounted for in this 
simple manner, but which may begin in the pelvis of the kidney, 
travel down, and subsequently involve the bladder. If they do occur 
the infection takes place through the blood, for in no other way can 
we account for such a course of the infection. • 

Cystitis is a common affection of infancy and childhood. Esch- 
erich called attention to it and cases have been described by Trumpp, 
Holt and others. 

Etiology. — The most frequent cause of cystitis is the Bacillus coli 
communis, as first demonstrated by Escherich, though other bac- 
teria, such as the Gonoeoccus, the Staphylococci, Streptococci and 
typhoid bacilli may all cause cystitis. The direct inciting causes 
are exposure to cold or any inflammation about the urethra or vulva 
in the female. It is found to complicate the infectious diseases, 
such as scarlet fever, measles, pneumonia, diphtheria, and inilm i 
A large percentage of cases certainly complicate some disturbance 
of the functions of the intestines. Tims a large 1 number of mv cases 
complicated or were preceded by some form of quasi-enteric infection 



94 



DISEASES OF KIDNEYS AND UROGENITAL TRACT. 



and diarrhoea. This corresponds with Trumpp's experience. In 
such cases the theory holds that through uncleanliness the bladder 
has become infected through the urethra. This mode of infection 
will not hold in boys in whom the urethra is long and the infection 
in them is more probably systemic through some lesion in the mucous 
membrane of the intestine. 

Frequency. — Of 36 of my own cases only 7 occurred in male chil- 
dren, thus showing the predominance of the affection in the female 
sex. This can only be accounted for by the ease with which infec- 
tion travels from the introitus vaginae into the urethra and bladder 
in the female. Of the 37 cases, 20, more than half, occurred in 
infants under one year of age, showing the susceptibility of infants 
who are still using diapers. Only 5 cases occurred after the fifth 
year. One case occurred in a newborn infant ten days old. 

Fig. 181. 





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Characteristic curve of temperature in cystitis or pyelitis of infancy. 



Symptoms.— The symptoms of cystitis in infants and children 
are not sufficiently characteristic to direct attention to the affection 
unless the physician bears the possibility of its occurrence in mind 
in every case of fever of obscure, origin. The main features are 
fever, frequency of urination, pain on urination, recurrence of chills, 
and staining the diapers in young infants a peculiar yellowish tinge. 

Fever. — The characteristic of the fever is that it is high with 
remissions to the normal (Fig. 181). It may be 104° to 106° and 
still the infant may not appear to be very much prostrated. With the 
fever there is the occurrence of chills. The patient becomes blue and 
pale and in some cases there may be, in susceptible infants and in 
the newborn, convulsions. The fever lasts for days or weeks and 
even when the affection is improving there may be recurrences. 



DISEASES OF THE UROGENITAL TRACT. 795 

Pain. — I have obtained a distinct history of pain in urination, 
the urine being passed with tenesmus and in small quantities. 

Ancemia.— Quite characteristic of all cases of cystitis in infancy 
is a marked and increasing anaemia after the disease has lasted for 
a period of one or two weeks. This anaemia is quite easy of recog- 
nition and after having seen a number of these cases this striking 
feature in infants who have a febrile movement of obscure origin 
will direct one's attention to an examination of the urine. With the 
anaemia there is loss of weight and the musculature loses its tone. 
There may also be disturbances of the functions of the intestine, as 
evinced by abnormal movements. 

Urine. — The urine is acid in reaction, turbid, contains nocculi of 
fibrin, pus, and a small amount of albumin. Microscopically it 
contains a large quantity of pus-cells, some bladder epithelium ; in 
severe cases renal epithelium, hyaline, epithelial casts, and blood, 
and Bacterium coli communis or other bacteria mentioned. 

Diagnosis. — The diagnosis is made from the presence of fever 
where every other cause has been excluded, the history of chills, the 
progressive anaemia, all in the face of a history of bowel disturbance 
or grippe should lead to an inquiry into the condition of the urine. 
In many infants who have been trained the urine can be easily 
obtained by placing them on the commode. In other cases the sim- 
plest procedure is to catheterize the infant. The appearance of the 
urine even before microscopic examination will lead to the diagnosis. 

In all cases of cystitis in infants and children the kidneys 
should be carefully palpated in order to discover an involvement of 
these organs. If they are involved they can be distinctly felt 
through the abdominal walls as markedly enlarged and tender. In 
such a case the diagnosis of a complicating pyelitis or pyelonephritis 
is warranted. 

Course and Termination. — A majority of my cases have recovered 
within the short time of one, two or more weeks ; others have not had 
such a favorable ending, especially cases whose onset has been over- 
looked and the diagnosis delayed for weeks. In these the urine con- 
tinued to contain pus and casts for months with no prospect of any 
clearing up of the urine under energetic management. The infants 
wore not at all badly affected by the disease, but increased in weight 
and their color improved. In the cases which I saw in older chil- 
dren and stud Led in the hospital mixed infection of the urine occurred 
after a time and the reaction became alkaline with the presence of 
Staphylococci and Streptococci in the urine. Among my cases there 
was one in a newborn infant which developed bacillsemia and finally 
a meningitis due to coli bacilli. Here the convulsions were repeated 
with every appearance o( a chill. The child did not die, but recov- 
ered, a hydrocephalic idiot. 



796 DISEASES OF KIDNEYS AND UROGENITAL TRACT. 

Ill one case of an infant six months of .age, pyelitis developed 
with suppurative nephritis and the kidneys after death were very 
much enlarged and studded with abscesses, being similar to a sur- 
gical kidney. Finally another case proved fatal through pyelitis 
and septic nephritis. Thus we cannot say what the outcome of any 
case may be before treatment, but should warn those concerned of 
the seriousness of the prognosis. Any involvement of the kidney 
clouds the prognosis unless the infection of the kidney is only 
temporary. 

Treatment. — There must be a large number of cases which run a 
mild course and which recover with very little but symptomatic 
treatment. There are infantile cases in which the diagnosis has 
been overlooked. The dangers which threaten have been dwelt 
upon. The treatment consists in placing the bowels in a correct con- 
dition, and administering salol or urotropin. Infants will take two 
or three grains of either drug without any danger three times daily. 
If urotropin is not well borne and gives rise to diarrhoea or bloody 
urine, salol is substituted. An alkaline water is given in the food, 
the so-called Poland water being the most available. In convales- 
cence citrate of potash is used, grs. v, three times daily. Saccharine 
is given in older children as in the adult. The question of bladder 
irrigation arises. My experience in acute cases is that irrigation of 
the bladder with various solutions is unsatisfactory. In the chronic 
and subacute cases they have seemed in my hands to have availed. 
The bladder is washed out once a day. In children it is a simple 
and harmless procedure if utmost cleanliness is observed. In those 
cases in which the kidney had become involved surgery in my hands 
has not held out any encouragement, though if marked pyelonephrosis 
occurs the surgical indication is evident. Treatment should not be 
suspended until it is certain that the urine has cleared and is in a 
normal condition. 

Bacilluria. — Bacilluria is a peculiar condition observed by Esch- 
erich, Trumpp, Box and others, which differs from the condition 
just described in that the urine does not contain pus but only bacilli 
coli. It is a form of bacteriuria. This condition may precede 
the development of cystitis and pyelitis. It is uncommon. 



SECTION XV. 

DISEASES OF THE NERVOUS SYSTEM. 

CONVULSIONS IN INFANCY AND CHILDHOOD. 

Eclampsia Infantum. — Convulsions are a series of violent clonic 
contractions of a number of muscles, or of the muscles supplying one 
limb. There is always more or less of a tonic spasm at first. The 
convulsions are paroxysmal and accompanied by a loss of conscious- 
ness. In this section the acute convulsions of infancy and childhood 
are especially considered, and will be differentiated from certain 
spasmodic affections, such as laryngismus, tetanus, and epilepsy, 
which are accompanied by spasms, though classed by some as forms 
of convulsions. 

Classification. — Convulsions of infancy may be classified as those 
which are primary or idiopathic, and those which are secondary, 
reflex, or symptomatic. In the first rubric are included the con- 
vulsions which occur spontaneously, or after some sensory irritation, 
very often of an obscure origin, such as epileptic, hystero-epileptic 
seizures, and tic. With increasing knowledge this class is gradually 
becoming more and more limited. 

In the second class the symptomatic or reflex convulsions are 
included : (a) the cases which follow abnormal conditions of the 
circulation in the brain, such as anaemia or hyperemia; (&) con- 
vulsions which occur at the outset of infectious diseases; (c) convul- 
sions which are caused by disturbance of metabolism, and which 
occur at the outset or in the course of certain diseases in which toxins 
are thrown into the blood; (d) those which follow some peripheral 
irritation, such as occurs in a reflex manner in wounds, burns, etc., 
or directly reflex, as in meningitis, tumors of the brain, hydroceph- 
alus, brain compression, poisons circulating in the blood (lead). 

Occurrence. — The acute convulsions of infancy and childhood are 
symptomatic, and occur chiefly during the first half year of life. 
Fully four-fifths of the cases occur before the end of the second year 
of life. They are uncommon after this period; but a child who has 
had convulsions of the symptomatic type in infancy is likely to have 
a recurrence of the convulsions up to the seventh year o\ childhood. 

Etiology. —The occurrence of convulsions necessitates not only 
the presence of an exciting agent or irritating substance, bur there 
must exist a certain constitutional disposition or predisposition to 

707 



798 DISEASES OF THE NERVOUS SYSTEM. 

convulsions, which may be hereditary. Soltmann has shown that in 
the newborn animal irritability of the motor nerves is almost nil, 
and that of the sensory nerves much below what is attained in later 
life. In the newborn, also, there is an absence of reflex inhibition, 
and the brain lacks volition ; in other words there is an absence of 
the psycho-motor centres. The inhibitory centres do not develop in 
parallel lines with the peripheral irritability of the sensory nerves. 
Reflex irritability is very much diminished at the outset, but in- 
creases later, becoming, at a certain period of infancy, above what is 
found in the adult. The musculature of the infant, on account of 
the instability of the nervous centres, can be thrown into tetanic con- 
traction by the least irritation. This period of increased reflex irri- 
tability of the nervous centres has been placed experimentally by Solt- 
mann at from the fifth to the eleventh month of infancy, thus corre- 
sponding with what is found in the human subject clinically. 

Although the theories of Soltmann are not wholly endorsed by 
other observers, it remains true that in infancy the inhibitory centres 
are not fully active, that the psychomotor centres are absent, and 
that this is a period of increased reflex irritability of the peripheral 
nerves. In a causal sense, not only does this increased reflex irri- 
tability predispose to acute convulsions in infancy and childhood, but 
with it there is a hematogenous toxic element especially active at 
this period of life. 

In infancy we have also the hereditary predisposition to neuroses, 
and tendencies derived from neurasthenic, alcoholic, syphilitic, and 
tuberculous parents. 

It seems, therefore, that causal agents of acute convulsions in 
infancy and childhood are principally periodical toxins, such as are 
present in the circulation (hematogenous) at the outset of infectious 
diseases, as acute amygdalitis, exanthemata, typhoid fever, malaria, 
influenza, pertussis, mumps — all of which may be ushered in with 
a convulsion. 

The explosion appears to be caused by the initial effect of the 
toxins and temperature on the ganglion-cell. Convulsions sometimes 
take the place of the initial chill in pneumonia and malarial fever. 

The disturbances of metabolism which may cause toxins to be 
thrown into the circulation occur in connection with gastro-enteric 
disease of any kind or with indiscretions in diet. Children who eat 
an excessive quantity of meat are particularly subject to these seiz- 
ures. In addition to the above exciting agents we have mentioned 
also disturbances of the circulation which may cause convulsions, and 
these are found in connection with pertussis, bronchitis, and heart 
disease. In these affections there is an accumulation of carbonic 
acid gas in the circulation, which is the exciting agent of the initial 



CONVULSIONS IN INFANCY AND CHILDHOOD. 799 

explosion; and, finally, we have as causes of convulsions the direct 
effect of mineral poisons, such as lead, circulating in the blood. 

Convulsions, according to some authors, may be caused by the 
presence of alcohol in the mother's milk. This is a very question- 
able cause of convulsions. Rarely, convulsions may be caused by 
reflex irritation of a foreign body in the stomach, or by overdi reten- 
tion of the stomach during stomach-washing, an instance of which the 
author has seen ; by burns, wounds, effects of cold, incarceration of a 
hernia. Retention of urine may, by reflex peripheral irritation, 
cause convulsions. The toxic form of convulsions occurs in uraemia. 

Dentition is frequently mentioned among the causes of convul- 
sions. Since dentition in a normal infant is devoid of symptoms, 
it is straining a theory to ascribe convulsions to irritation of the 
trigeminal branches. The acceptation of this dentition theory might 
lead one to overlook some serious condition, of which the first indica- 
tion is an eclamptic seizure. 

i Under the heading of circulatory disturbances might further be 
mentioned an acute cerebral anaemia, caused by severe hemorrhage, 
which may give rise to a convulsion. Such convulsions are hardly 
included under the conception of infantile convulsions of the acute 
type. 

Pathogeny. — The pathogeny of convulsions in infancy and child- 
hood is the same as in the adult. The explosions are due to irrita- 
tion of the centres in the ponto-bulbar junction, or in the area of 
Rolando (Hughlings Jackson). The starting-point of every convul- 
sion is a ganglion-cell. It is not known whether the inherited neu- 
rotic tendencies already mentioned are powerful factors during 
infancy, or whether alcoholism or epilepsy in the family are active 
in causing convulsions of the purely acute type in infancy. Rachitic 
children, however, according to Kassowitz and Elsasser, are pecu- 
liarly subject to convulsions, because the cranial bones are the seat 
of hyperemia and softening. The motor areas adjacent to these 
points of hypersemia and softening are supposed to be in a state of 
constant irritability. 

Kussmaul and Tenner have demonstrated that there is an acute 
anaemia of the brain during convulsions. On the other hand, it often 
happens that the convulsion is the cause of the bursting of a cerebral 
vessel. In such cases the signs of cerebral surface hemorrhage are 
present at autopsy. In other cases, although death has occurred 
during a convulsion, nothing is found postmortem but an oedema of 
the brain substance, of doubtful origin. 

Symptoms. — The majority of convulsive seizures in infants and 
children are single. In certain cases the convulsions are repeated 
and extend over a prolonged period. The latter are not cases 



800 DISEASES OF THE NERVOUS SYSTEM. 

simple acute infantile convulsions. The symptoms of acute eclamp- 
sia are sometimes so very slight as to be scarcely noticeable. A very 
observant mother will see a slight twitching of the lips and eyelids, 
a momentary turning of the eye and cessation of breathing, or a 
momentary spasm of the whole trunk. The expression " internal 
convulsion/'' so frequently heard, evidently denotes these slight 
eclamptic seizures. The genuine convulsion comes on without pre- 
monitory symptoms. There is a momentary spasm of the body, the 
head turns to one side and upward, and there is a corresponding 
upward direction of the eye. Then follow a series of clonic spasms 
involving the upper and lower extremities, and lasting for some time. 

The hands are clenched, the forearms flexed, the body rigid, 
the lower extremities extended, the head thrown back. This tonic, 
momentary spasm is followed by a clonic spasm, beginning in the 
muscles of the face and involving those of the trunk and extremities. 
The teeth are set, the tongue is protruded and may be bitten. There 
are cyanosis and frothing at the mouth. The respirations are short 
and hissing, the pulse is imperceptible, and at the outset of the con- 
vulsion the heart becomes slow and irregular. A cold perspiration 
bathes the surface. The convulsive seizure may be momentary, may 
last a few minutes to a quarter of an hour, or one spasm may be fol- 
lowed rapidly by others extending over the same period of time. 
Toward the termination of the convulsive spasm the clonic contrac- 
tions become less frequent ; the child passes into a sleep or coma. In 
some cases the clonic spasms may be limited to one side of the body. 

The child may be in a state of eclampsia for an hour, after which 
it may pass into the comatose state. The coma may be momentary 
or may merge into a sleep of variable duration. The end of the 
convulsive spasm is signalized by muscular clonic spasms decreasing 
in severity, until finally a long-drawn inspiration ends the attack. 

Diagnosis. — It is very important to be able to distinguish between 
the various forms of convulsive seizures. Those occurring imme- 
diately after or within a few hours or days of birth have a different 
significance from those just described. They may be caused by cere- 
bral hemorrhage, and there will be symptoms after the convulsions, 
such as palsies, contracture, difficulty in deglutition, and prolonged 
coma. In these cases the convulsions are repeated. Atelectasis of 
the congenital variety may cause convulsions. The patients have 
slight or marked cyanosis, and, in the intervals, increase of respira- 
tions and signs of bronchitis and collapse of the lung. 

Tumor and abscess of the brain, and meningitis, both cerebro- 
spinal and tuberculous, may be ushered in by convulsions. In 
tumor, the convulsions are limited to the area in which the tumor or 
abscess is localized. In forms of meningitis, there will be the symp- 



' CONVULSIONS IN INFANCY AND CHILDHOOD. 801 

toms of that disease. Drugs and poisons may give rise to convul- 
sions. The history of such cases will be of service. Cases of tetany 
and tetanus have convulsions in the course of the disease. In tetany 
there may be several convulsions in the course of twenty-four hours. 
Tonic spasm is the chief feature of the convulsion in tetany and 
tetanus. The clonic form distinguishes acute convulsions. In 
tetanus there is slowly increasing opisthotonos. In tetany the body 
may be lax in the interval, but there are rare cases of tetany which 
resemble tetanus in that there is rigidity in the intervals between the 
spasms. In tetany the extremities have a characteristic position. 
In some cases of simple acute infantile convulsions, an increased irri- 
tability of the nerves and muscles to mechanical stimulus remains 
for days after the paroxysms. The Chvostek and Trousseau phe- 
nomena are found. Some authors have regarded these cases as cases 
of latent tetany. The diagnosis of the various epileptiform seizures 
will be considered in the section devoted to that subject. 

Prognosis.- — The prognosis of acute infantile convulsions is gen- 
erally good, but since death has occurred in these seizures, as well as 
cerebral hemorrhage, caution should always be exercised in predict- 
ing the immediate outcome. The patient having been once tided 
over the initial paroxysm, it may be confidently expected that it will 
not be repeated. In the presence of fever, it cannot be predicted 
what affection may follow the seizure. Primary seizures should 
not be regarded as forerunners of epilepsy. Many infants and chil- 
dren affected with convulsive seizures pass through later life without 
any sign of that disease. 

Treatment. — The seizure is frequently over before the physician 
arrives. If such is the case and the infant is in the stage of stupor, 
it should not be disturbed unless there is high fever or a history of 
the patient's having eaten some irritating substance. It often hap- 
pens that the paroxysm supervenes in the presence of the physician. 
The patient is placed on a bed, the clothes loosened, and a small 
object, such as the handle of a tooth-brush, placed between the teeth 
to save the tongue from injury. Nothing further is needed. The 
paroxysm is as a rule over in three minutes at most. If it persists 
or is immediately succeeded by another, the patient is placid in a 
warm bath, after which a few drops of chloroform are administered 
by inhalation to control the convulsions. A high rectal enema of 
the temperature of 110° F. (43.3° C.) is at once administered. 1 
have in some cases continued the administration o( chloroform for 
fully an hour. Caution should be exercised in its administration. 
If, after the sci/ure, the temperature is high, ii is treated as indi- 
cated in the seel ion on Enfectious Diseases. Unless there is some 
contraindication, a full doso oi' calomel is administered as a routine 

51 



802 DISEASES OF TEE NEBVOUS SYSTEM. 

procedure even if an enema has been resorted to. Should the child 
be restless, it is well after the convulsion to administer a dose of 
bromide of potassium in combiuation with chloral, either by mouth 
or rectum. In repeated convulsions the administration of these 
drugs during the seizures is of inestimable value. 

For several years past I have used the postural treatment in acute 
convulsive seizures. The patient is placed with the head low, the 
buttocks raised, and the clothes loosened. I think the paroxysms 
have been shortened by this treatment. It was suggested by the 
theory that cerebral anaemia is the cause of the initial paroxysm. I 
have carried out this postural treatment without any ill after effects, 
such as hemorrhage. In a large number of cases of repeated con- 
vulsions, the postural treatment should be supplemented by chloro- 
form inhalations. 

HYSTERIA. 

Hysteria is a morbid state of the nervous system in which the 
primary derangement is in the higher cerebral centres. The lower 
centres of the brain, the spinal cord, and the sympathetic system may 
be secondarily disordered (Gowers). It is not a true disorder of 
childhood. Sixteen per cent, of all the cases of hysteria occur in 
youth (Steiner). 

Etiology. — Hysteria is rarer in children than in adults, is more 
frequent in the female sex, and is more often seen in boys than in 
men. According to Briquet and Landouzy. 8 per cent, of all the 
cases occur in the first decade of life, and 50 per cent, in the second. 
The cases of the first decade, according to Barlow, generally develop 
at the age of six years. Cases are occasionally seen in patients of 
the age of three years. Heredity plays an important etiological role. 
Moral and mental influences predispose to development of the con- 
dition. Children of emotional antecedents are apt to be subject to 
the disease. Sexual disturbances or excesses (as masturbation in 
boys) are exciting causes. Abnormalities of the sexual organs, phi- 
mosis, and hypospadias are apt to excite masturbation and resultant 
hysteria. In some subjects, any acute disease, such as pneumonia or 
typhoid fever, will develop latent tendencies to hysteria. Diph- 
theritic paralysis may eventuate in hysterical palsy (Gowers). 

Symptoms. — The disease shows many variations and most diverse 
symptoms. The symptoms may be divided into psychic, motor, and 
sensory manifestations; or into the convulsive and non-convulsive 
forms of hysteria. 

Psychic or Ifental Hysteria {Non-convulsive). — In most cases 
of this class, the patients suffer from some mental strain. The 
attack begins with a paroxysm of crying or of laughing. The child 



HYSTERIA. 803 

then passes into a violent condition, striking at persons and tearing 
the clothes from its body. I saw a case of this kind in a hoy eight 
years of age. He was very bright at school, but shunned the com- 
panionship of other boys. He masturbated. At times he was of a 
very loving disposition, at other times would refuse to do as he was 
told. The rebellion would terminate in a paroxysm of crying, fol- 
lowed by one of shrieking. The boy would tear his clothes and then 
calm down quite exhausted. Girls after undergoing some mental 
strain, such as is incident to a school examination, become irritable, 
morose, and suffer from insomnia. They have laughing and crying 
spells and refuse nourishment. After a period of these symptoms 
they either recover or pass into a state resembling acute mania. 
Such children are nervous and are born of neurotic parents. 

Hystero-epilepsy, catalepsy, or trance symptoms may manifest 
themselves. These cases are rare in children, but Sachs and Steiner 
have seen them in children of mentally degenerate families. 

Insanity, alcoholism, and chorea in the family predispose to the 
development of hysteria. These cases must be differentiated from 
those of true epilepsy. 

Motor Manifestations (Convulsive Forms). — These occur in the 
form of hystero-epileptic attacks. After some mental excitement a 
paroxysm beginning with a shriek will supervene, the sounds simu- 
lating a bark or a snapping sound. Contortions then supervene and 
the back is arched, as shown in Richer's drawings. During the 
attack, which may last for several minutes, there may be no evidence 
of consciousness. There may be a number of such attacks in the 
course of twenty-four hours. The patient may suddenly fall down 
and have contortions, and the attack may terminate in a crying spell. 
The patients sometimes tear, their clothing and become violent. 
These convulsions are differentiated from true epilepsy in that there 
is no aura ; they are preceded by emotional excitement. The onset 
is gradual and the patients emit noises of various kinds during the 
attack. The pupils are normal. There are ecstasy, extravagant 
movements, and tonic rigidity. The vesical and rectal reflexes are 
normal. The patients do not bite the tongue, and rarely injure 
themselves; the loss of consciousness is temporary or imperfect. 
There are in hysteria irregular twitchings of the extremities and a 
repetition of one specific movement, such as retraction of the head. 
The spell or paroxysm ends in a crying or laughing fit, or the patients 
become melancholic. 

Among the manifestations o( hysteria in children is the so railed 
hysterical stricture o( the oesophagus, or globus hystericus. There 
may be spasm oi' the bladder, hiccough, and loss of voice. The latter 
is common among young girls, 1 have seen the children recover 



804 DISEASES OF THE NERVOUS SYSTEM. 

their voice under hypnotic suggestion. Hysterical children may, 
even at the early age of five years, pass under hypnotic suggestion, 
into a trance-like state. Whether diarrhoea can be caused by hysteria 
is in my opinion doubtful. I have seen true toxic diarrhoea in neu- 
rotic children diagnosed as nervous or hysterical. One case occurred 
in a boy of six years. Some young girls have attacks in which all 
varieties of poses are assumed in the nude state. I have seen such 
a case in a highly intelligent girl of nine years. During the morn- 
ing bath the child had a desire to assume the most grotesque poses. 

The so-called epidemics of chorea are now known to be simple 
hysteria. Among these are to be classed the school epidemics and 
the dancing mania of the Middle Ages. 

There may not only be convulsive movements, but also absolute 
paralysis of single muscles or of a group of muscles. Hysterical 
paralyses as a rule follow no anatomical distribution. They are dis- 
tinguished from true palsies by the lack of change in the electrical 
reactions and in the condition of the deep reflexes. The sphincters 
are normal. Paralyses, such as those due to neuritis or poliomye- 
litis, may supervene in a hysterical subject. 

Disturbances of Sensation. — The disturbances of sensation in- 
clude hyperesthesias and anaesthesias. These do not differ essen- 
tially from similar conditions in the adult subject. There may be 
hyperesthesia in the region of the ovary, or in the skin over the 
vertebral column. Areas of irritation may cause paroxysms. There 
are hysterogenic zones which are not hyperaesthetic (Sachs). Anaes- 
thesia, partial or general, is more frequent. There may be absolute 
anaesthesia to all sensation. There may be blindness in one eye or 
hemianopsia, deafness, or loss of taste or of smell. Vision may be 
affected as above described, or there may be photophobia and diminu- 
tion of visual perception ; the retina may be insensible to light, and 
there may be limitation of the field of vision or temporary bilateral 
loss of sight. 

There are in children cases of anorexia which supervene with 
vomiting after some nervous strain. I have seen this occur in chil- 
dren who were beginning some course of study. In one case it came 
on in the morning just before the child started for school. With 
suspension of school duties, the vomiting ceased. The so-called 
phantom abdominal tumor seen in rare instances among children 
may be traced to a hysterical cause. In very young girls I have fre- 
quently seen forms of palpitation with cardiac anguish which seemed 
to be hysterical. Steiner describes these forms of tachycardia. In 
these cases there is not only absence of cardiac lesion and signs of 
Basedow's disease, but spinal hyperesthesia may be elicited. 



BAD HABITS. 805 

Diagnosis. — Sensitiveness to pressure over the vertebra] column 
is one of the most frequent stigmata of infantile hysteria (Steiner). 
Epigastric tenderness is less frequent than among adults. Hyper- 
esthesia is less marked in childhood than later in life, hut is more 
common than anaesthesia. Jolly says that deep analgesia is rare. 
Of especial interest in its relation to diagnosis is the fact that ocular 
symptoms, such as diplopia, may be present morning and evening. 
Paralysis may appear and disappear. There are forms in which 
there may be tachycardia or bradycardia, but during excitement the 
rhythm of the heart may be normal. Cases have been described in 
which the headaches, ptosis, and facial palsies simulate the symptoms 
of tuberculous meningitis. Study alone will clear up such obscure 
cases. 

Duration and Course. — The symptoms of hysteria are not neces- 
sarily permanent, but are likely to recur after excitement or nervous 
strain of any kind. 

Treatment. — The treatment of hysteria in children is based on the 
same general principles as in the adult. The child is, if possible,, 
removed from exciting surroundings. Studies are regulated and 
bad habits, such as masturbation, are, if possible, corrected. The 
effect of good food and outdoor life is marked. Hydrotherapy and 
massage achieve their greatest triumph in this affection. 

BAD HABITS. 

By the term bad habits are meant a number of so-called " tricks "" 
in which neurotic children are apt to indulge. They are not neces- 
sarily a"n indication of any serious nervous functional derangement. 
It is difficult to say from a purely clinical standpoint whether such 
bad habits lead to any serious results. They are in most cases easily 
controlled either by close attention to the cause or by a complete 
change in the surroundings of the patients. 

Pica or Dirt-eating. — Thomson has interested himself in the 
study of this peculiar condition in children. It is an exaggeration 
of the normal habit seen in young infants who invariably place every- 
thing within reach in their mouths. As the infant develops, its 
sense of good and bad taste teaches that certain substances are un- 
wholesome, others not. In children who suffer from pica or dirt- 
eating this sense of what is wholesome is lacking. There is an unex- 
plainable yearning after queer articles of diet, such as sand, dirt, 
gravel, cinders, plaster from walls, or paper. Some o( these chil- 
dren are normal in other ways, others arc the victims of so-called 
cachectic conditions. If the habit has been indulged in for any 
length of time the children become cachectic. In fact, many of 



806 DISEASES OF TEE XEEVOUS SYSTEM. 

these children become the victims of intestinal parasites (hook-worm) 
and others develop a chronic inflammatory state of the stomach or 
intestine. J. Lewis Smith published a case in which a hair-ball 
was found in the stomach of such a dirt-eating child. 

Treatment. — The treatment is one of vigilance on part of the 
nurse or guardian in preventing the indulgence of this abnormal 
appetite. A change of scene sometimes causes the patient to forget 
his habit. If cachexia exists, the fasces should be examined for the 
ova of parasites which may have infested the intestine as a result of 
dirt-eating. 

Puddling in Water or Biting the Finger-nails. — These are among 
other habits of extremely neurotic infants and children. 

Thumb Sucking. — Much attention has been directed to thumb 
sucking by recent writers. Lindner, who has analyzed these cases, 
divides them into two classes, those of pure thumb sucking and those 
in which there is combined with this another habit, " combination 
cases." In the latter the other hand is brought into use while the 
thumb is in requisition, either to hide it or to perform some other 
act, such as nose-boring or rubbing of the genitals. 

The simplest form of thumb sucking is seen in young infants, 
generally in atrophic infants. I have seen it in an atrophic infant 
of six weeks. In such cases the act can scarcely be classed in the 
same category as when seen in older children. In the former case 
it is the result at first of an instinctive need of the infant, probably 
a result of starvation. 

In older children it may be looked upon as an act of mental weak- 
ness; in fact, in boys and girls who practice these acts there is a 
tendency to mental obtuseness. The act seems to be accompanied 
by very little intent in most children, for when the attention is fas- 
tened on some other object the habit is quickly forgotten. In other 
children there is a distinctly surreptitious practice of the habits of 
combination thumb sucking and nose-boring or genital interference. 
The outlook in most cases is good and no ill effects result. In cases 
where the children are mentally backward the habit is but a symp- 
tom of general degeneracy. 

The inculcation of correct bearing and cleanliness by the nurse 
are in normal children enough to put a stop to the habit. 

Where the habit is the result of mental imbecility nothing can 
be done to break the habit except in a general educational way as a 
part of the treatment of the mental defect. 

Head-hanging, Swaying, Head-nodding, and Rolling the Head 
from Side to Side. — These have all been observed in mental defectives 
of various grades. The patients are young children. The habit 
occurs during waking and in most cases, if the children are defective 



BAD HABITS. 807 

normally, seems to be practiced in an automatic manner without pur- 
pose. In children who are otherwise normal the habit is not difficult 
to break. Some of the minor habits, such as body-swaying, head- 
hanging are sometimes seen in children who are subject to violent 
outbursts of temper. Such children, as one of my own cases, are 
not only mentally defective but moral perverts. 

Masturbation.- — Masturbation has received great attention in this 
country since first brought to the notice of the profession by Jacobi. 
Much is described as masturbation which is only a simulation of the 
habit as seen in older children above or near the age of ten years. 

Infants and very young children are sometimes affected with the 
habit of so-called thigh rubbing or buttocks rubbing. In them the 
sexual instinct can hardly be said to exist, though many of these 
infants present symptoms in the act of thigh rubbing which closely 
simulate an orgasm. It is probably far from such. Rachford has 
recently fully studied thigh rubbing. He calls it " pseudo-mastur- 
bation. 7 ' Most cases are seen in young infants ; the infant will rub 
the thighs together for a time and this will be accompanied, not by 
manifestations of pleasure, but rather of great nervous perturbation. 
The series of acts terminates in an apparent nervous exhaustion and 
the mothers will say the child seems as if limp and may fall asleep 
after the act. Most of the patients are female infants below the age 
of eighteen months, some as young as six months. 

Another form of pseudo-masturbation is seen in infants who as 
soon as they are laid prone on their backs will start to rub the but- 
tocks vigorously on the couch. The motion is a side-to-side one and 
in this form of rubbing the infant may laugh and evince no nervous 
strain. In both forms of this affection there is found on close exam- 
ination some irritation at the introitus vagina?, or on the buttocks, 
or between the thighs to keep up this genital irritation. Rachford 
places great stress upon acidity of the urine as a causative factor 
in this irritation. I think most of these children are the victims of 
some oversight in the nursing, or of lack of cleanliness ; in male in- 
fants the prepuce is not scrupulously cleansed daily. I do not think 
these cases ever lead to any serious after effects, such as epilepsy, nor 
do I believe that adhesions either of the clitoris or prepuce are causa- 
tive in these cases. 

The operative treatment, either in loosening adhesions or freeing 
the clitoris, seems to me unwarranted, as in my hands close attention 
to the remedying of local conditions of irritation have effected cures 
without the use of any special apparatus. 

Masturbation, as it is seen in older children, is an entirely dif- 
ferent affection from that just described. Here the sexual instinct 
lias either prematurely developed or above ten years o( age it is 



808 DISEASES OF THE NERVOUS SYSTEM. 

actually present. We then have true masturbation. Masturbation 
is an exceedingly prevalent habit among children of all classes. 
There is a tendency to interfere with the genitals common to both 
sexes. Only the flagrant cases come under the notice of the physi- 
cian. The children may be bright, others are not so bright, but all 
are highly neurotic and come of neurotic stock. 

Most serious are the cases in which the habit is practiced in 
secret. Here we have evident interference with the mental peace 
of the patient. Other cases are seen in children who are quite inno- 
cent of any immoral intent. Such was a case of mine in which a 
child with high moral standards contracted the habit from irri- 
tation of the vulva as a result of horseback riding. A cessation of 
the horseback riding and local treatment with moral suasion was 
enough to cure the habit. In boys the problem of curing becomes 
very difficult. The only way seems to me to be educational explana- 
tion and a stimulation of the mind to moral cleanliness. Any use of 
mechanical apparatus is certainly degrading to sensitive children and 
leads to no good results. In those cases in which the habit is the 
result of a general mental defectiveness the treatment and manage- 
ment of the masturbation becomes one of the features of the general 
management of these cases. 

TETANY. 

(Tetanilla; Arthrogryposis.) 

Tetany is an intermittent or persistent, more or less painful 
tonic spasm of groups of muscles of the upper and lower extremities. 

Forms and Frequency. — Haviland in 1813 and Clark in 1815 de- 
scribed this disease in children. Trousseau, Baginsky, Chvostek, 
Erb, and Escherich have completed its symptomatology. It is most 
frequent from the third month to the end of the second year of life. 
Griffith found that 68 per cent, of the cases occurred before the 
second year of childhood. The greatest number of cases occur in 
the eighth month of infancy (Escherich). As to age, the forms are 
the infantile, the tetany of early and late childhood and adult tetany, 
including the surgical variety. As to duration, we have the forms 
in which the contractures are intermittent, coming on at intervals, 
the patients being free from muscular spasm in the intervals. The 
second form, now accepted by the majority of writers as the same 
affection as the former, is that in which the contractures are persistent. 

Etiology. — The etiology of this affection is still very obscure. It 
occurs most frequently in the winter and early spring. In my expe- 
rience in an ambulatory clinic, it was customary to see these cases 
appear in groups in the early spring months. The affection is seen 



TETANY. 809 

under the most diverse conditions. Fully 63 per cent, of the cases 
are rachitic (Fischl). The percentage of rachitis must, of course, 
vary in different countries, but the cases coming under my notice 
have been chiefly of that character. The condition is not, as is fre- 
quently supposed, a rare one. I have regularly seen a number of 
these cases yearly. Many cases of tetany are not recognized as such 
by the physician. Cold, entozoa, infections of the gut, chronic 
intestinal disturbances of all kinds, rachitis, an enlarged thymus 
(Escherich), have all in turn been regarded as etiological factors. 
On the other hand, some attribute the affection to a toxaemia prob- 
ably originating in the gut and expending itself on the peripheral 
motor nerves. Fully 73 per cent, of Fischl's cases had shown intes- 
tinal disturbances. The fact that the condition occurs in early 
infancy and in some respects resembles a normal state, to be de- 
scribed later, will account for its being frequently overlooked by the 
physician. 

The symptoms of tetany are traced by Stoltzner and Cybulski 
to a deficiency of retained calcium salts in the body. Under a cow's 
milk diet only half of the calcium is retained as compared to a 
breast-milk diet. This is not generally accepted. Escherich and 
Erdheim recently proved that in tetany there is a species of para- 
thyroid priva, a deficiency in the function of these glands. He has 
found lesions in the parathyroids of infants dying of tetany. Such 
lesions may interfere with the function of the parathyroid under 
exciting causes of malnutrition or infectious diseases. With this 
there is an unequal distribution of calcium salts in the body (Leo- 
pold), and from this tetany may result. 

Morbid Anatomy. — No definite account of the changes in the 
nervous system or elsewhere has as yet been given. Langhans has 
described a peri-arteritis and phlebitis in the white commissure and 
cervical portion of the cord. Gowers, without any positive data, 
assumes that there are some changes in the motor cells of the cord 
which cause the increased irritability of the peripheral motor nerves. 
Fischl in a recent article has published the postmortem changes in 
his fatal cases. Tie makes, however, no comment on them. He 
found hydrocephalus interna and externa, oedema of the brain and 
meninges, tuberculosis of the brain, hemorrhagic infiltration of the 
cerebellum and meninges, chronic intestinal catarrh, ami broncho- 
pneumonia. The affection occurs under the most diverse conditions. 

The investigations of Erdheim on rats and of Escherich in the 
human have revealed hemorrhages and epithelial lesions in the para- 
thyroid bodies or epithelial bodies. In one of my cases of tetany 
such hemorrhages were substantiated. 



810 



DISEASES OF THE NERVOUS SYSTEM. 



Symptoms. — The symptoms consist of muscular contractures and 
phenomena connected with the peripheral motor nerves, which are 
known as Trousseau's phenomenon, Chvostek's facial symptom, and 
Erb's signs of increased electrical excitability of nerve and muscle. 

Muscular Contractures. — These come on without any premoni- 
tory symptoms. The infant or child may have been in good health, 
or may have been suffering from intestinal disturbance. There are 
two distinct forms of contracture in infants, in one of which the 



Fig. 182. 


/ \ 


q^m & 


^-3^4,, 



Tetany. 



Extension of the fingers, flexion of the arms, flexion of the toes. Fades. 
Child, eighteen months of age. 



hands and arms take the position assumed in driving horses (Plate 
XXXVI. ). The arms are pressed against the thorax, the forearms 
flexed on the arms, and the fingers tightly flexed over the thumb into 
the palm of the hand. The hand itself is strongly flexed on the 
forearm. The lower extremities may be adducted toward the me- 
dian line, the thighs flexed on the abdomen, and the legs on the 
thighs. The feet are as a rule extended in the equinus position and 
the toes overflexed on the plantar aspect of the foot, the whole foot 



PLATE XXXVI 




Tetany. Infant nine months of age. Shows the driving 
position of the fingers, hands, and arms, overextension of 
the feet and flexion of the toes. 



TETANY. 8 1 1 

being slightly curved inward. After the contractures have lasted 
some time, there is oedema of the tissues over the dorsum of the foot. 
In the second set of eases the fingers are overextended, as shown in 
Fig. 182. The arms and lower extremities also take the position 
of flexion. These contractures are painful; the patient cries as if 
in great pain when an attempt is made to straighten the fingers or 
extremities. There may be a temperature of two or three degrees. 
The contractures may diminish, and there may be an interval in which 
the only symptoms are such as may be attributed to the increased 
mechanical and electrical irritability of the peripheral nerves. There 
may also be eclampsia. The eclamptic attacks are very dangerous. 
I have lost 2 cases in such seizures. Other muscles, such as the 
abdominal or thoracic, may be the seat of contracture. In the latter 
case there may be cyanosis. 

I have seen cases in which all the muscles of the body were 
involved very much as in tetanic conditions. In one case there were 
stiffness of the muscles of the neck and loss of consciousness. Tris- 
mus is rare, and certainly does not occur at the outset, as in tetanus. 
The muscles of the face may be subject to contracture. The brow 
is wrinkled, and the face has an anxious expression. If the muscles 
over the zygoma are tapped, there is an instantaneous contracture 
or spasm of the orbicularis palpebrarum. In some cases, if the 
muscles of the face or the forehead are tapped, there is an instanta- 
neous contracture of the muscles of the face, and sometimes of other 
muscles of the body. This is called the facial phenomenon of 
Chvostek. If the nerves and arteries at the bend of the elbow are 
compressed, the characteristic tetany position is produced in the 
muscles of the hand and fingers. This phenomenon was first noticed 
by Trousseau, and bears his name. Erb established the fact that 
there is increased irritability of nerve and muscle to the faradic and 
galvanic current. If the muscles or nerves elsewhere in the body 
are tapped, or if pressure is brought to bear at the point of exit of 
the nerve-trunks, there is an excessive irritability to this mechanical 
stimulus. The knee reflex is increased. 

Escherich and V '. Pirquet have recently shown that there is in 
tetany an increased electrical excitability of nerve to low stimuli. 
With a current of four milli amperes there is muscular contraction on 
kathodal opening and closure as well as anodal opening and closure. 

Duration.- -The disease may last a few hours, days, or weeks. In 
many eases the contractures disappear for a time, leaving the patient 
perfectly free from symptoms. They may return in all their orig- 
inal severity. The attacks leave the peripheral nerves in a condition 
of increased excitability, In such cases both the Chvostek and 
Trousseau phenomena may be present. 



812 DISEASES OF THE NERVOUS SYSTEM. 

Diagnosis. — The diagnosis of fully developed tetany is based on 
the presence of muscular contractures, of increased electrical and 
mechanical irritability of the peripheral nerves (as evinced in Chvo- 
stek's symptom) and the presence of Trousseau's phenomenon. There 
are cases of tetany in which the facial symptoms are lacking. On 
the other hand, I have, in cases in which there was laryngospasm with- 
out contractures, obtained both the facial and Trousseau phenomena. 

The Relationship of Laryngospasm to Tetany. — Escherich, his 
pupil Loos, and also Ganghofner, have recently called attention to 
the fact that laryngospasm is present in a certain number of cases 
of tetany. They also found that cases of laryngospasm which did 
not present contractures, did show the facial phenomenon of Chvostek 
and the Trousseau symptom. They concluded that laryngospasm 
was a manifestation of tetany, whether the muscle contractures were 
present in the extremities or not. Their observations have been 
amply confirmed, but not all observers are as yet willing to accept 
laryngospasm without contractures of the muscles of the extremities 
as true tetany. The views of Kassowitz and Hochsinger are at 
variance with those of Escherich. They consider rachitis the fun- 
damental cause of laryngospasm, if not of tetany. 

Latent Tetany. — The term latent tetany has been applied to those 
cases which show no muscular contractures or laryngospasm, but in 
which the facial Trousseau or Erb phenomenon may be elicited, or 
in which the mechanical, and especially the electrical, contractibility 
of muscle and nerve are increased. 

Accidental Symptomatic Form of Infantile Tetany. — There are 
forms of tetany which occur in a symptomatic way in combination 
with other diseases; such are called the accidental tetanies. They 
occur mostly beyond the third year of life and in children who as 
a rule have suffered from convulsions and laryngismus, and in whom 
the symptoms of tetany reappear in concurrence with some acute 
disease, such as pneumonia. 

In these children we have the facial phenomenon, typical elec- 
trical reactions, and the tetanic contractions of the hands and lower 
extremities. Such a recurrence has been observed by Finckelstein 
in grippe, influenza, whooping cough, acute gastro-enteritis, etc. 
These cases have been more or less confused with those of meningitis. 

Persistent Form of Infantile Tetany. — This is characterized by its 
long duration. The muscular contraction is not so marked and 
tetanic as in the acute cases, but manifests itself rather in in- 
creased contractions of all the muscles of the affected part of the body, 
a hypotonia of the muscles, and difficulty and slowing of the volun- 
tary motion. The muscles are hard, contracted and in severe cases 
rather prominent. The contractures are mostly bilateral and affect 



TETANY. 813 

by preference the distal end of the extremities. Thus we have 
manifested the " accoucheur" position of the hands, supination and 
flexion of the feet which occurs in the typical tetany conditions. 

In some cases there is the picture of simple hypotonia existing 
during rest or sleep. The active muscular motion is slow and per- 
formed with difficulty, as if overcoming some resistance. In some 
a high degree of muscular tension is present, voluntary motion is 
entirely impossible and we have the picture of a spastic contracture 
which affects the muscles of the trunk and face, causing neck rigidity 
and opisthotonos. These cases may very closely resemble the so- 
called "womb" tetany and they have been called pseudo-tetanies. 
Especially interesting are cases in which there is only contraction 
of muscles of one side of the body, or contraction of a particular 
group of muscles. 

There have been no postmortems in these cases, and the question 
as to whether these cases are those of true tetany is still in doubt. 

Escherich insists that inasmuch as the pathognomonic electrical 
reactions are present in these cases, they should be classed as tetany. 

In addition we have the Erb, Chvostek, and the Trousseau phe- 
nomenon, extending over a long period of time. 

Late Tetany: Tetany of Later Childhood: Puerile Tetany. — By 
puerile tetany we mean that occurring after the third year of life. 
These cases are distinctly separated from those of infantile tetany, 
and in them the main symptoms of the clinical picture of infantile 
tetany, such as laryngospasm and convulsive attacks, are relegated 
to the background. On the other hand, muscular spasm, especially 
the typical carpo-pedal spasm accompanied by pain and hyperes- 
thesia, is quite marked. On this account, the shorter duration and 
the better prognosis of the disease is explained. In this respect 
puerile tetany resembles very closely the tetany of adults. 

Prognosis and Mortality. — The prognosis in the sporadic cases is 
very good. The gravest cases are those in which convulsions and 
laryngospasm are combined with symptoms of tetany. Parents 
should be cautioned in regard to the excitability of the patient and 
the possibility of eclampsia, with its fatal consequences. I have lost 
4 cases in convulsions. The persistent cases may be complicated 
with other affections, such as tuberculous meningitis. If such is the 
case, the outcome is, as in the primary disease, fatal. Epidemics 
in hospitals for children present unfavorable features: Escherich lost 
37 per cent, of his cases. 

Treatment. The bowels should first be evacuated, Cajomel is 
given in grain \ (0.03) doses two or three times daily. If there is 
any disturbance of the gut, the patient is given n high enema once a 
• lav. ]\Iilk is suspended until the movements take on a more favor- 



814 DISEASES OF THE NERVOUS SYSTEM. 

able appearance. The infant is kept under the influence of the 
mixed bromides of potassium, sodium, and ammonia. If there is 
eclampsia or increased irritability, a warm bath is given at least 
once a day. The patient is kept quiet and not disturbed much. No 
attempt to straighten the limbs should be made, since it causes pain. 

Fig. 183. 









Cataleptic state produced in a child following typhoid fever. 

In view of the fact that cases of surgical tetany are improved by 
calcium lactate, this drug has been recommended in infantile tetany. 
Five grains are given internally three times daily. Feeding is of 
first importance and breast-milk is the most desirable food. 

CATALEPSY. 

Epstein has described a condition in children closely resembling 
a similar affection in the adult. He has described it as catalepsy 
occurring in infants poorly nourished and rachitic. The ages of his 
cases ranged from eighteen months to three and one-half years. 
Epstein believes there is a disturbance of the psychomotor functions. 
The phenomenon was observed by him chiefly in the lower extremi- 
ties. Either extremity on being lifted into the air would stay there 
for a length of time in any position of flexion or extension in which 
it was placed. This phenomenon was not present during sleep, nor 



CONGENITAL STRIDOR OF INFANTS. 8 ] 5 

was it accompanied by any muscular rigidity or increase of mechan- 
ical or electrical irritability of the peripheral nerves. I have met 
a marked case of catalepsy following an attack of typhoid fever in a 
child of four years. The hands, arms, and lower extremities would 
remain for long periods of time in the position in which they were 
placed. The patient would sit for long periods staring ahead, with- 
out winking the eyes (Fig. 183). 

MYOTONIA. 

Myotonia physiologica neonatorum is a term applied by Hoch- 
singer to the normal tendency of the newly born infant to ilex the 
fingers, arms, and lower extremities. There is a slight rigidity which 
is a hypertonicity of the muscle, and which lasts until the third 
month. The position closely resembles that of the extremities of the 
foetus in utero. The myotonia is exaggerated if the infant becomes 
ill with any intercurrent affection, such as syphilis. The condition 
cannot be mistaken for tetany if the differences between the normal 
and the abnormal states of the peripheral nerves are borne in mind. 

CONGENITAL STRIDOR OF INFANTS. 

(Thomson.) 

This rare condition has for a long time been classified by writers 
as a mild form of laryngismus stridulus. I have seen one case in 
which there was also laryngismus. The affection is a distinct one, 
is generally congenital, and appears soon after birth. Some years 
ago, I presented a case of the kind before the Pediatric Section of 
the Academy of Medicine of ISJew York. Since then I have seen a 
number of cases. Thomson has fully described and studied the affec- 
tion. The infant is usually in other respects normal, but I have 
seen the condition in infants with signs of rachitis. The ages of the 
patients varied from nine weeks to twelve months. In one ease there 
was a history of attacks of laryngismus stridulus, occurring shortly 
after birth. In most of the cases, the symptoms were noticed soon 
after birth. The respiration is more or less noisy, being sometimes 
scarcely audible and at other times so loud as to be heard at some 
distance. Inspiration is accompanied by a peculiar croaking, grunt- 
ing noise. 

As a rule, expiration is noiseless, but it may be accompanied by 
a grunting sound, there being shorl intervals in which no sound is 
heard. The infants are not at all disturbed by the condition. They 
sit and play, emitting this peculiar croak while breathing. In mild 
cases, nothing is seen in the thorax. 1 have, however, seen the draw- 



816 



DISEASES OF THE NERVOUS SYSTEM. 



Fig. 184. 



ing inward of the suprasternal region which Thomson describes. In 
one case the noise was louder at night. If the stethoscope is held 
over the situation of the vocal cords, it will be ascertained that the 
sound is produced in the larynx and not in the pharynx. 

The causation is obscure: the theory advanced by Thomson is 
that there is an ill-coordinated spasmodic action of the muscles of 
respiration, choreiform in character and similar to that present in 
stammering. This influence, acting on the epiglottis from birth, 
causes a deformity of the organ, which in turn perpetuates the crow- 
ing noise. Others have attributed this condition to the presence of 
an enlarged thymus (Variot). Some of these infants are distinctly 
lymphatic, and Hochsinger has lately with x-raj demonstrated what 
he believes to be an enlarged thymus in many of the cases of laryngeal 
stridor coming under his notice. He believes the condition due to 

an enlarged thymus, and suggests that 
the term '"Asthma thymicum" be ap- 
plied to these cases. Lee and Eefslund 
have published two cases with autopsy 
in which laryngeal stridor existed from 
birth and in which there was an anatom- 
ical malformation of the epiglottis. 
This consisted in a folding of the epi- 
glottis laterally, so that the aryepiglottic 
folds were almost in contact. The supe- 
rior opening of the larynx was thus cov- 
ered by the deformed epiglottis in such 
a way that respiration took place through 
a mere slit of epiglottis, hence the grunt- 
ing or sawing noise. I have recently 
published a case of laryngeal stridor 
dying of intercurrent pneumonia (Fig. 
184). This case showed the same mal- 
formation of the epiglottis described by Lee and Eefslund, and would 
support the theory of anatomical deformity as a causative factor in 
these cases. Toward the second year of life the condition gradually 
disappears spontaneously. 




Larynx from author's case of 
laryngeal stridor. Patient 13 
months of age. 



LARYNGISMUS STRIDULUS. 

(Spasyn of the Glottis.) 

Laryngismus stridulus is a spasmodic functional nervous disorder 
of the glottis, involving the muscles of inspiration and expiration. 

Occurrence. — The affection is more frequent in boys than in girls. 
It is most common in the first year of life. The majority of the 



LARYNGISMUS STRIDULUS. 817 

cases occur before the end of the second year. Kassowitz found 
348 of 370 cases to occur before that time. It may occur in the 
newly born infant (Henoch, Kassowitz). Most of the infants and 
children affected by this disorder are subjects of rachitis and also 
show signs of craniotabes. Henoch estimates the frequency of 
rachitis at 75 per cent. Only one of the cases of Kassowitz did not 
show its signs. All but 48 showed craniotabes. On the other hand. 
Boral shows that 4 per cent, of all children with rachitis have laryn- 
gismus stridulus. 

Etiology. — The etiology of this affection is obscure. Although 
rachitis is so frequent an accompaniment of the disorder, it may not 
yet be assumed that it is the exciting cause. Craniotabes, which 
is a part of the symptom-complex, has been regarded as the cause 
(Elsasser). 

Escherich, Loos, Gee, and Ganghofner have placed laryngismus 
stridulus in the same category as tetany, and trace it to the same 
exciting cause. Reflex irritation from the stomach acting through 
the vagus is the theory of Baginsky. In many cases which have 
terminated fatally an enlarged thymus has been found. On the 
other hand, there have been postmortems which showed a rather 
small thymus and slightly enlarged bronchial nodes (Baginsky). 

Morbid Anatomy. — No definite study has been made of the changes 
found in the fatal cases. Most cases show oedema of the brain and 
some fluid in the ventricles, rachitis slight or pronounced, the thymus 
small or enlarged, and the lymph-nodes slightly enlarged. The cases 
with enlarged thymus thus far published have not been convincing. 
Children with enlarged thymus die of other disorders, and without 
having had during life any symptoms of spasm of the glottis. 

Symptomatology.- — The spasm or paroxysm comes on suddenly. 
Without the least warning, the child throws the head back and stops 
breathing ; the face becomes livid, the arms are flexed and the hands 
clenched. No respiratory movement takes place for a few seconds. 
There is then a long-drawn whistling or crowing inspiratory sound. 
This is the classical form of spasm of the larynx. The paroxysm 
may begin with a piping, inspiratory sound. Apnoea lasting for a 
varying length of time succeeds, and is followed by a loud or silent 
expiration. Apncea may appear first, and be followed by several 
noisy explosive expiratory movements, which may be succeeded In- 
several noisy crowing inspiratory sounds. The picture is usually 
that of spasm of the glottis as first described, in which the breathing 
stops entirely. The attack may come on during absolute quiet or 
during sleep, the onset of the attack causing the child to wake. 

The paroxysms may be brought on by excitement, a draught of 
air, or by pressure 1 on the Larynx. They are of all degrees of severity. 



818 DISEASES OF THE NERVOUS SYSTEM. 

Some infants show a form which is very disquieting. In a fit of 
crying the child takes a number of noisy inspirations and expira- 
tions, and then stops breathing, becomes cyanosed, clenches the hands, 
and threatens to pass into an eclamptic paroxysm (expiratory apnoea), 
when suddenly a deep inspiration occurs and the danger is passed. 
Some cases of the classical form have eclamptic seizures. There may 
be convulsions, especially in the form described as expiratory apnoea. 

One of my cases was that of an infant a year old, one of twins. 
The infant was anaemic, and showed marked signs of rachitis and 
craniotabes. It was in apparent health until the eighth month of 
infancy, when attacks of respiratory apnoea appeared at first at inter- 
vals of three weeks, and finally daily. The infant during a crying- 
spell would stop breathing, become cyanosed, the left hand and arm 
and lower extremity and muscles of the face contracted in tonic 
spasm, during which the heart became very slow in action and irreg- 
ular. The left-sided spasm lasted for a few seconds, and then the 
infant relaxed and quietly passed into a sleep, from which it awoke 
in a few moments. In all of these cases there is the ever-present 
danger that the glottis and the muscles of respiration, including the 
diaphragm, will fail to relax, thus causing death with convulsions. 
The number of attacks of spasms of the glottis may reach twenty or 
thirty a day, or they may be very infrequent, occurring only once 
every few days, weeks or months. In all the forms, including the 
classical one just detailed, the spasm involves not only the glottis, 
but also the diaphragm and other muscles of respiration. The in- 
fants may show no symptoms after the paroxysms. On the other 
hand, some infants seem to be overcome and pass into a stupid state 
lasting for fully ten minutes. It is difficult to estimate the degree 
of consciousness during an attack, but even in the mildest forms 
there may be a momentary loss of consciousness (Henoch). Most 
cases show the facial and Trousseau symptoms of tetany and in- 
creased irritability of the peripheral nerves. 

Prognosis. — The prognosis of spasm of the glottis is good. The 
danger lies in the eclampsia, during which death may supervene. 

Diagnosis. — The diagnosis is not difficult. There are all degrees 
of severity of the spasm, ranging from partial to complete closure of 
the glottis. In the latter form a rachitic infant in a paroxysm of 
crying is frequently heard to give several inspiratory crowing sounds 
without having any further symptoms. There is a species of laryn- 
geal inco-ordination. These cases may at intervals develop typical 
paroxysms. The parents should be warned of this possibility. The 
forms of spasm of the glottis which have just been described should 
not be confused with spasm or difficult breathing due to pressure of a 
retropharyngeal abscess or suppurating gland upon the larynx. 



EPILEPSY. 8 1 9 

Complications. — Pertussis may complicate a case of spasm of the 
glottis. Cases thus complicated give a grave prognosis (Henoch). 
Tetany has been elsewhere mentioned as an accompanying condition. 

Treatment. — During the Attach. — The infant is carried to an open 
window. A draught of air is allowed to blow in its face or a few 
drops of water are thrown in the face. This is done to excite a reflex 
relaxation of the glottis. The head should be held low, as in ordi- 
nary eclampsia. If relaxation of the glottis does not occur and con- 
vulsions set in, a few drops of chloroform may cause the muscles of 
respiration and those of the glottis to relax. Intubation and trache- 
otomy have been performed at this crisis, when the breathing threat- 
ened to cease permanently. If, however, as sometimes happens, the 
muscles of respiration are also involved, the paroxysm will occur with 
the tracheotomy tube in the trachea. Stork has published a case in 
which the insertion of a tracheotomy tube had not the least influence 
on the paroxysms. This is a very important observation, and raises 
the question of the propriety of intubating or performing tracheotomy. 
On the other hand, cases have been intubated and resuscitated with 
artificial respiration (Pott). 

In the Intervals. — In the intervals, the treatment should be 
chiefly directed toward the rachitis. The feeding should be carefully 
attended to ; the infants should, if possible, be breast-fed. Bottle-fed 
infants should be fed on raw milk, beef -juice, orange-juice, cereals, 
and eggs. The medicinal treatment which in my hands has given 
the best results has been the administration of an albuminate, or pep- 
tonate of iron or manganese in full doses. To prevent the recur- 
rence of the laryngismus or apnoeic attacks, full doses of the mixed 
bromides are given. To an infant one year of age as much as 5 
grains of the mixed bromides of sodium, potassium, and ammonium 
are given three times daily, and continued over some period of time. 
Under this medicinal treatment I have been able to control apnoeic 
attacks. In my hands the administration of phosphorus has not 
been attended with any success. 

Bathing in cold water has not in my experience been productive 
of good results. 

EPILEPSY. 

Epilepsy is not a disease peculiar to infancy and childhood. It is 
discussed here simply to emphasize the peculiarities o( fche affection 
as they occur in children. It is a true disease o( the nervous system, 
and has nothing in common with and no demonstrable relationship 
to infantile convulsions. Fifteen per cent. o\' the eases ot' epilepsy 
occur before the fifth year of life. Henoch has seen a case in an 
infant one year o( age who had convulsions beginning with a erv 



820 DISEASES OF THE XEBYOVS SYSTEM. 

and during which the infant bit the tongue. He describes another 
case in a child three years of age, in which the attack began with 
vertigo. In another case, in a child three years of age, the patient 
fixed a point and ran blindly toward it. The latter appears to have 
been a case of "procursive epilepsy.'' 

Etiology. — According to Gowers, in two-thirds of the cases of 
epilepsy in children the parents are neurotic and hysterical. Chorea 
in the mother will often manifest itself in epilepsy in the child. 
Infantile palsy or traumatism is more frequently than heredity the 
cause of epilepsy. Epilepsy following slight palsy is likely to be 
mistaken for hereditary epilepsy. 

Symptoms. — In children, as in the adult, there are no symptoms 
in the intervals between the attacks. Only such results of attacks 
as a bitten tongue or local traumatism are seen. There are, as in the 
adult, two distinct forms of epilepsy — grand and petit mal — between 
which there may be all variations participating in the peculiarities 
of both forms. In grand mal there is the aura, sensory or psychic ; 
it is present in a large percentage of the cases in children. 

Aura. — Baginsky calls attention to a case in which epigastric pain 
was the aura preceding the attack. The other forms of aura are 
numbness and tingling of the extremities, general restlessness and 
irritability and auditory phenomena in which a peculiar cry of an 
animal is perceived. There may be a hissing sound. An aura 
referred to the sense of taste is very rare, and most neurologists do 
not make note of having found it in any case. In children the 
perception of peculiar odors just prior to the attack occurs as a form 
of aura. 

After the aura, the attack begins with a cry followed by sudden 
loss of consciousness and tonic or clonic spasm of the muscles, which 
may be unilateral, general, or partial. The pupils dilate; there is 
spasm of the respiratory muscles and those of the jaw, as well as 
foaming at the mouth and biting of the tongue. The spasm then 
relaxes, the movements become first clonic and then intermittent, 
there is involuntary passage of urine and faeces, and consciousness 
gradually returns, the patient passing into prolonged stupor and pro- 
found sleep. Some of these symptoms may be absent, but the loss 
of consciousness, dilated pupils, spasm, and the succeeding profound 
sleep are constant. In the majority of cases, the presence of any two 
of these will be sufficient for a diagnosis. 

Convulsions. — General convulsions indicate hereditary epilepsy. 
Convulsions may at first be partial, but in the majority of cases 
eventually become general. Partial convulsions indicate disease in 
the motor areas. The attacks taking the form of petit mal may be so 
slight as to be mistaken for fainting spells. Such attacks may 



PAYOR NOCTUBNUS. 821 

occur in young children. One of my cases was i u a child of five yea rs 
of age. An epileptic spell is momentary; a fainting spell is gradual. 
there are no vasomotor disturbances, and the pupils do not dilate. 
Henoch and others record cases in which the children momentarily 
stop the occupation in hand, stare into vacancy, and then recover them- 
selves without having any recollection of the interruption. In other 
cases there is an irritable attack or mild maniacal outbreak. In some 
cases the child passes into a state of mental confusion in which it per- 
forms acts unconsciously. Attacks of double consciousness or nar- 
colepsis are rare in children (Sachs). 

Temperature. — Attacks of grand mal are sometimes associated 
with a rise of temperature. A case recently came under my observa- 
tion in which a girl of eight had as many as forty convulsive seizures 
in twenty-four hours. There was a slight rise of temperature which 
could not be traced to any cause other than the convulsions. Thom- 
son and Oppenheim have shown that there are a concentric limitation 
of vision and a diminution of general sensibility for some time after 
the epileptic attack. 

Diagnosis. — Epilepsy must be differentiated from syncope, hysteria, 
post-hemiplegic convulsions, and tumor of the cerebrum. The pecu- 
liarities of an attack of syncope and hysteria have been dilated upon. 
The post-hemiplegic convulsions will, in the intervals, reveal the 
paralyses and contractures with increase of deep reflexes. Attacks 
of convulsions caused by tumor are confined to groups of muscles if 
the tumor is in the motor area, and are combined with optic neuritis 
if the chiasm is directly or indirectly the seat of pressure. 

With tumor, there are in the intervals peculiarities of the gait 
and epileptic attacks. 

Treatment. — The treatment of epilepsy is essentially the same in 
children as in the adult subject. 

PAVOR NOCTURNUS. 

(Night-terrors.) 

There are two forms of this affection — the primary or idiopathic 
and the symptomatic form. In both, the children retire to sleep 
and after an hour or two suddenly awaken from deep slumber with 
a shriek or cry. They are pale, greatly terrified, and grasp al the 
empty air. In incoherent, broken phrases they try to collect their 
thoughts. Some children see terrifying visions and either cling to 
ihe bystander for protection or try to gel out of bed to escape an 
imaginary danger. Aiter being quieted the children fall asleep, and 
wluai questioned the next morning have no distincl recollection of 
whal lias occurred. These attacks may occur everv nighl for days. 



822 DISEASES OF THE XEEVOUS SYSTEM. 

weeks, or months. They rarely occur twice in the course of the 
same night. 

The idiopathic form of this affection may occur in children who 
are naturally of a nervous temperament without any apparent excit- 
ing cause. I have seen it in children who were distinctly the oppo- 
site of nervous, and who were well nourished and good natured. 
The night-terrors may follow epilepsy or they may be so severe as to 
be the exciting element in precipitating an attack of chorea. Chil- 
dren sometimes have real hallucinations, which may be present even 
during the day (Henoch). It may, however, be said that halluci- 
nations during the day are really not included in the idiopathic form. 
This affection occurs chiefly up to the time of second dentition. 
Forms of terror in older children are hysterical. Adenoids are sup- 
posed to be an etiological factor, but this is doubtful. It is only in 
the symptomatic form that children, after having committed some 
error in diet, awake with the symptoms above described. 

Prognosis. — The prognosis is good. The affection never precedes 
insanity. It subsides under treatment or disappears spontaneously. 

Treatment. — In the symptomatic form, the meals should be so 
arranged that the lightest repast is that taken in the evening. In the 
idiopathic form, bromide of potassium is most useful. It is admin- 
istered in one dose, an hour before retiring. The children should 
not be too active mentally during the daytime. Visitors should be 
restricted to certain hours. Play and sport in the open air are indi- 
cated. The school tasks of older children should be completed in the 
afternoon. 

CHOREA. 

(St. Vitus' Dance; Sydenham's Chorea.) 

Chorea is a nervous disease characterized by irregular involuntary 
movements or twitchings of some or all of the muscles of the body. 
It is accompanied by muscular weakness and mental disturbances. 
In some cases there is endocarditis. 

Classification. — Chorea minor is an acute disease described by 
Sydenham. Chorea major is a hysterical disorder ; under this head- 
ing are included the chorea electrica, and the dancing mania with 
rhythmical motions, of the Middle Ages. 

Chorea insaniens is the fatal form of acute chorea minor. 

Laryngeal chorea is a hysterical affection (Gowers). 

Choreiform affections or pseudochoreas comprise the cases of tic 
convulsif of French writers and other forms of habit-spasm, local 
or general. 

In addition there are forms of chorea which are symptomatic 



CHOREA. 823 

or secondary to infantile palsies. Huntington's chorea is a chronic 
progressive affection of a hereditary nature. 

All these forms of chorea except chorea minor and insaniens 
should he excluded from the category of Sydenham's chorea. 

The epidemics of so-called chorea, occurring in schools, are prob- 
ably hysterical disorders which are the result of imitation and not 
true Sydenham's chorea. 

Frequency and Etiology.' — Chorea is more common among female 
than male children. Of 554 cases collected by Osier, 70 per cent, 
were of the female sex. It rarely occurs before the fourth year. 
Starr's statistics of 1400 cases show 8 at the third year. Cases are 
recorded as occurring in newly born infants, but are not accepted by 
all authors as authentic. The disease is most common from the fifth 
to the fifteenth year. Fifty per cent, of Starr's 1400 cases occurred 
before the tenth year, and 75 per cent, from the fifth to the fifteenth 
year. Of 83 cases of chorea occurring in my ambulatory and hos- 
pital service, 23 were of the male and 60 of the female sex. Ten 
children were under the age of five years, and 67 cases occurred from 
the fifth to the tenth year. Thus, the greatest frequency is at the 
latter period. Only one case occurred in a very young child (two 
and one-half years). The disease is found in children in all walks 
of life. 

Children of a nervous, ambitious temperament with a hereditary 
neurotic history are more prone to contract this disorder than those 
of a more equable disposition. It is therefore more common in towns 
and large cities than in country districts. In some cases there is a 
history of fright or traumatism, either immediately preceding an 
attack or coincident with its onset. It is as yet impossible to say, 
however, whether there is any relation between chorea and these 
occurrences. They may have some influence in developing latent 
tendencies to the disease. An attack will often be initiated by a 
scolding or chastisement on the part of parents. The spring months 
show the greatest number of cases, the least number occurring in the 
late autumn. There also appears to be a correspondence in the preva- 
lence of cases of chorea and rheumatism at certain periods of the 
year (Osier, Lewis). The relation of a condition of lymphatism 
(adenoids or nasal catarrh (Jacobi)) to true Sydenham's chorea is 
not generally eccepted. Errors of refraction in the eves also seem 
to be a predisposing cause of the outbreak of choreic attacks (de 
Schweinitz). These can scarcely be regarded as a direct cause of 
Sydenham's chorea, but acute articular rheumatism may bo so 
considered. 

Rheumatism seems to run in families in which the children have 
chorea. Osier finds thai L5 per cent, of his cases are of such families. 



824 DISEASES OF THE NEBVOUS SYSTEM. 

Of the subjects of chorea, fully 21 per cent, show a history of rheu- 
matism (Osier). These figures correspond more or less to the sta- 
tistics of Townsend. 21 per cent. : Starr. 21 per cent, in 1400 ca- - : 
and my own cases. IS per cent. Crandall gives the highest frequency 
of rheumatism in cases of chorea (54 per cent.). In the majority 
of cases the rheumatism precedes the chorea (See). I have seen one 
case of chorea preceding an attack of rheumatism in a child four years 
old. I believe that, with cases of rheumatism of the acute articular 
type, there should also be included those of articular pains without 
swelling of the joint. The forms of rheumatism with chorea giving 
the so-called subcutaneous fibrous rheumatic nodules are rare in this 
country (Osier). 

Chorea may complicate any acute infectious disease, such as scar- 
let fever ; whooping-cough, measles, diphtheria, typhoid fever, and 
forms of sepsis. There are. however, no definite data of the exact 
relation, if there be such, between chorea and the infectious diseases. 
The theory that an attack of any of these diseases will cut short an 
attack of chorea is not borne out by clinical experience (Henoch). 

Morbid Anatomy. — The pathology of chorea is still incomplete and 
can therefore be merely indicated. Hyperemia of the brain and 
cord were found by Pye-Smith and Ogle. Anaemia and prolifera- 
tion of connective tissue were recorded by Steiner. In the cases of 
ACeynert there was hyaline degeneration of the nerve cells of the 
central ganglia. Tlechsig mentions hyaline degeneration of the len- 
ticular nucleus. Dana studied some cases in which he found hyper- 
emia of the brain, and degenerative changes in the walls of the 
bloodvessels of the white substance, with perivascular exudation and 
accumulation of leucocytes. Jackson has advocated the embolic 
theory (endocardial). At present there is a great preponderance of 
evidence in favor of the infectious theory. Berkeley found staphylo- 
cocci in the blood in a fatal case of chorea. In another case. Xaunyn 
found cladothrix in the meninges and endocardial vegetations. It 
is certain that just as rheumatism and endocarditis are infectious 
diseases, so chorea in many cases can only be understood on that 
theory. Cesaris-Demel has experimentally shown that the central 
nervous system is peculiarly susceptible to certain pathogenic micro- 
organisms and their toxins. The staphylococcus and its toxins when 
injected experimentally under the dura mater cause the formation 
of small foci of inflammation, and symptoms very similar to those 
of chorea. 

Symptoms. — Children will at the outset of this disorder exhibit 
mild symptoms of nervous irritability, will be cross, have outbreak- 
of peevishness and temper, will drop things, and be generally careless 
in their habits. There is sometimes a historv of ni^ht-terrors or 






CHOREA. H'2?) 

morose crying spells. There is likely to be loss of appetite ; headache 
is not uncommon, and there may be pains in the limbs or joints and 
general restlessness. The disease may begin in a certain set of 
muscles, or in the muscles of one-half the body and thence spread to 
the whole trunk. Of 301 cases of the statistics of Sachs, there was 
hemichorea or involvement of one set of muscles in 67. Of Starr's 
1400 cases, 951 were general and 449 unilateral, the right side being 
affected more frequently than the left. When fully developed, the 
picture presented by these patients is so characteristic as to be easily 
recognized. On the other hand, the popular notion, so prevalent even 
among physicians, that every twitching is choreic, has led to grave 
errors. The following are the main symptoms : 

Motor. — The twitchings usually begin in the right hand, only 
rarely in the legs. After a time there are incessant, irregular, awk- 
ward twitchings of all the muscles of the body, which are intensified 
by volition. If the child is directed to stand still, with the feet 
together and the arms and hands held out at right angles to the body, 
the motions are intensified. If it is told to close the eyes, there is a 
distinct swaying of the body. The movements are not only irregular, 
but awkward. The patients trip in walking, upset their food and 
drink, and cannot button their clothing with ease. As a rule, the 
muscular twitching ceases in sleep, but it may persist. The mus- 
cular power is weakened, although distinct paralysis does not occur. 
The muscle is more paretic than paralytic. Some children let the 
arm hang at the side. There is wrist-drop when the children are 
asked to hold out the arms. The tongue is affected in all cases. 
Sachs places much diagnostic value on the choreic movements of that 
organ. When children are asked to show the tongue, they will pro- 
trude the organ with a jerk, then withdraw it and twist it here and 
there in the cavity of the mouth. When the tongue is held out 
quietly, fibrillary twitchings in the organ may be detected. Elec- 
trical reaction or irritability of the muscles in chorea can be tested 
only when the disease is unilateral. In some cases there is no change. 
In others, according to Gowers, there is a distinct increase in the 
galvanic and faradic irritability of nerve and muscle. The muscles 
of the hands, face, and extremities are all involved in the twitchings 
of the voluntary muscles. The involuntary muscles, such as the car- 
diac muscle, are not affected. Their involvement has long been a 
matter of discussion. 

Disturbances of Sensation. — Disturbances of sensation are not 
common. Children have the arthritic pains. Numbness, tingling, 
pricking, and aiuvsihesia of tho pharynx are recorded. Attacks 
multiple neuritis and epileptic seizures should bo regarded as compli- 
cations. The reflexes arc not markedly affected, Thev mav in rare 



126 



DISEASES OF THE NEEVOVS SYSTEM. 



cases be slightly diminished or increased (Henoch). Any marked 
change in the reflexes may be traced to changes of an organic nature, 
in the cord. The occurrence of headaches or eye-strain as concomi- 
tant conditions has been referred to. 

Urine. — The nrine may contain albumin. Cases with nephritis 
as a complication have been reported (Thomas). 

Speech. — The speech is affected in 25 per cent, of the cases. The 
patients hesitate and mumble their words or there is difficulty of 
phonation due to inco-ordinate action of the larynx. Laryngeal 
chorea, in which there is a distinct sound resembling a bark, is seen 
in rare cases. It is classified by Gower as a hysterical disorder, truly 
choreic. I have never met a case of the kind in a child. Deglutition 
mav be affected because of the muscular inco-ordination. 



Fig. 185. 






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Chorea. Recurrent attack of moderate severity. Systolic murmur over the aortic area. 
Fourteen days of the temperature is shown here. Child, twelve years of age. 



Cardiac Symptoms. — The cardiac symptoms are the most impor- 
tant clinical feature of chorea. There is very little doubt that in a 
fixed proportion of cases, rheumatism plays an important role and 
that the rheumatic poison, whatever it may be, expends its force upon 
the endocardium and pericardium. In 20 per cent, of the cases of 
Osier and in 12 per cent, of Starr's material, organic lesions of the 
heart were found. 

The frequency of cardiac disease in chorea varies as given in 
hospital and ambulatory statistics. The severer cases come to the 
hospitals. The majority of the ambulatory cases are mild. Thus 39 
per cent, of my hospital cases showed a cardiac lesion (endocarditis), 
while only 13 per cent, of the ambulatory cases were similarly affected. 
There would thus be an average of 26 per cent, of both hospital and 
ambulatory cases. The lesions in simple chorea referable to the 
endocardium usually affect the mitral valve. Of 17 valvular lesions, 
14 occurred at the mitral valve (systolic). The aortic valve was 
affected in 3 cases (Fig. 185). Pericarditis occurred in one of my 
cases. In the majority of cases in which there was endocarditis 
either the patient or the parents gave a rheumatic history. 



CHOREA. 



827 



On the other hand, not all murmurs of the heart are organic. In 
9 per cent, of Starr's 1400 cases, there were functional murmurs 
heard at the base and over the pulmonic area, early or late in the dis- 
ease. A gentle blowing at the apex which is heard to the left of the 
sternum and is not conducted into the axilla or arteries is heard late 
in the affection, and is undoubtedly hsemic or myocarditic (Osier). 
I have heard these murmurs in many cases and have come to the 
same conclusion. Murmurs may also arise at the tricuspid orifice. 
The organic murmurs are, as stated above, produced at the mitral 
orifice in the greatest number of cases. They may arise in the course 
of the disease or may appear during a relapse. Such cases will show 
a temperature (Fig. 186). 



Fig. 186. 



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Chorea. Endocarditis. Previous attack six months prior to the present illness, 
which was of five weeks' duration before the above observation. Pains in the joints, 
especially the knee. This curve shows two weeks of the endocarditis. Recovery. Female 
child, five years of age. 

The temperature may after a time become normal, and, in a week 
or more, while the chorea is still in progress there may be a rise last- 
ing for a day or more, after which it may then again subside to the 
normal. The temperature may be but a fraction of a degree above 
the normal, and the diurnal course may be distorted or subnormal 
(Jurgensen). There is thus clinically a true endocarditis. This 
form of endocarditis may pave the way for future chronic valvular 
disease. Under the heading of Chorea Insaniens, I have noted two 
fatal cases of this form of heart disease. Chorea of the heart muscle 
is not clinically recognized. Pericarditis with endocarditis may occur 
in cases of recurrent chorea. I have seen two such cases. Func- 
tional disturbances such as palpitation and arrhythmia also occur. 

Temperature. — There are some forms of chorea minor without 
any signs of endocarditis which run a course with a slight tempera- 
ture, the cause of which is undetermined. Some authors think that 
there may be a latent endocarditis in these forms o( chorea (Henoch). 
If endocarditis is present, there may be a temperature only slightly 
above normal. In mosl cases o( chorea there is no temperature (Fig. 
187). Fatal cases of chorea, with few exceptions, show signs of endo- 
carditis. Osier has made a study oi' 80 such cases, and found onlv 
5 which postmortem did not show changes in the valves. 



828 DISEASES OF THE XEEYOUS SYSTEM. 

The mental symptoms are in some cases marked. The patients 
show apathy and depression. The children often, while they are 
under treatment, have spells of mental depression and fits of crying. 
It is only in the cases of insaniens that delirium occurs. In severe 
cases there is a period of more or less mental depression, extending 
far into convalescence. 

Diagnosis. — The diagnosis of chorea minor is not difficult in the 
majority of cases. The picture is a very characteristic one. There 
are slight twitchings, which so closely resemble habit movements that 
it is not easy to come to a conclusion in regard to them. Sachs 
thinks that the twitchings of the tongue are a means of distinguish- 



Fig. 187. 


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Chorea, without endocarditis, two months in duration. No rheumatic history. Female 

child, nine years of age. 

ing the mild cases of chorea from cases of habit movements. If the 
patient is told to show the tongue, the tremors and twitchings of that 
organ and the facial grimaces at once become marked. The move- 
ments of the muscles are more rhythmic in hysteria than in chorea. 
True Sydenham's chorea should be distinguished from the chorea 
and athetoid movements seen in cases of infantile palsy. The his- 
tory of the cases, the paralysis, the condition of the reflexes and the 
contractures will be of assistance in making a diagnosis. True Syden- 
ham's chorea should also be differentiated from cases of tic convulsif 
and habit movements. A diagnosis of chorea, made in a case which 
has lasted for a year or more, is open to doubt. 

Duration. — The duration of chorea is variable. It may last from 
three to ten weeks, and may recur. The recurrent attacks are not 
necessarily any more severe than previous attacks. Fully one-third 
of the cases in some statistics show two or more attacks. Of Starr's 
1400 cases, 365, or 26 per cent., had relapses. One case had nine 
attacks. 

Prognosis.— The prognosis of chorea minor is very good. Recovery 
is the rule, but in exceptional cases it may be delayed for fully three 
months. 



CHORE A. 829 

Treatment.— The treatment of chorea consists at first in giving 
the patient perfect rest and quiet surroundings. Children are put 
to bed and kept free from excitement. I do not think it necessary 
to isolate them, and it is not wise to do so, since they may, under such 
treatment, become melancholic. An ordinary amount of quiet, such 
as is prescribed in cardiac cases, is all that is usually necessary. The 
patient may be allowed to look at picture-books, but not to study or 
to read. A simple, easily assimilable diet is indicated, milk and eggs 
being the chief articles. A warm bath is given daily and the spine 
sponged with cool water, as some authors recommend. I have not 
found this necessary in all cases, and would advise it to be omitted if 
the children strongly object to it. Massage is of great value with 
ansemic children in whom the circulation is below the average and 
who have no cardiac disease and no temperature. 

Drugs. — Fowler's solution is used almost as a routine remedy in 
these cases. In my experience its curative effects are doubtful. I 
therefore prefer to give it in small tonic doses, rather than risk the 
ill effects of large dosage. There are cases in which any attempt to 
administer it causes vomiting, and which therefore do much better 
without it. In any case it should be well diluted. In this way larger 
doses can be given for a greater length of time than would otherwise 
be possible. 

Cases which show recent or old endocarditis or which have artic- 
ular pains should receive antirheumatic treatment. Alkalies to keep 
the bowels open, alkaline baths, and sodium salicylate are the reme- 
dies in use in these cases. 

If there is great restlessness, bromides should be resorted to. It 
is a very good plan to combine the bromides of sodium, potassium, 
and ammonium in one mixture. Trional given in grain v (0.3) 
doses several times daily is a very good remedy in this set of cases, 
especially if there is wakefulness at night. 

If on account of the loss of appetite and general mental depres- 
sion it is not possible to give any drugs, the children are simply kept 
quit and given a nutritious diet. They frequently recover without 
the help of any drugs. In ordinary cases there is no necessity of 
using opiates, such as codeine. Antipyrin in grain v (0.3) doses has 
been recommended. I have not found it better than other remedies. 
Children who have recovered should be kept quiet for fear of a recur- 
rence of symptoms. This is especially true oi' eases in which the 
heart has been the seat of a recent endocarditis. 

Chorea Insaniens.- Chorea insaniens is a term appliechto the 
severest form of chorea. A large number of these cases run their 
course with delirium and high fever. It occurs especially in female 
subjects. At the outset there may appear to be nothing more than 



830 



DISEASES OF THE NEEVOUS SYSTEM. 





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He had chronic cardiac disease. 



an ordinarily severe chorea, but the 
patient rapidly becomes worse. De- 
lirium with hallucinations sets in, 
finally giving way to incoherency and 
mania. The patients are in inces- 
sant motion and do not sleep at night. 
The fever may mount as high as 107 ° 
F. (41.6° C). The cases are in 
many instances fatal. Osier gives a 
resume of some fatal cases. I have 
seen 2 fatal cases of this form. One 
case occurring during my service as 
interne at Bellevue Hospital was that 
of a girl of twelve, who died with 
symptoms very similar to those of 
acute mania. Another case, seen re- 
cently, was a boy of ten years, who 
had for two years previously suffered 
from ordinary chorea. He had a 
mitral regurgitant murmur. Two 
weeks before his death he was suffer- 
ing from a mild recurrence of the 
chorea. While in that state he was 
operated on for adenoids and enlarged 
tonsils. Chloroform was adminis- 
tered. Three days after the opera- 
tion the boy was taken with a chill, 
the chorea became worse, and there 
was fever. Examination of the heart 
showed endocarditis and pericarditis 
with dilatation of the left ventricle. 
In the second week the boy became 
delirious and did not sleep at night. 
He complained constantly of pain in 
the prsecordium and tossed in bed. 
He died two weeks after the onset of 
the disease. There was throughout a 
high febrile movement. A third case 
was that of a boy six years of age, 
whose temperature-curve is herewith 
appended (Fig. 188). This case 
occurred in my hospital service. It 
was the boy's third attack of chorea. 
In the final attack there was compli- 



FORMS OF TIC. 831 

eating pericarditis with effusion. The delirium was constant and 
the choreic movements incessant. He went into a typhoid state, but 
recovered, his mental faculties, however, being shattered. During 
the course of the pericarditis there was a polynuclear leukocytosis, 
and 45 per cent, haemoglobin. 

These cases are to be differentiated from cases of severe simple 
chorea, in which the movements are so incessant that the patients 
can with difficulty be kept in bed. In simple chorea there is no 
delirium and there is a period of quiescence at night. 

Treatment. — The treatment of chorea insaniens is symptomatic. 
The delirium and incessant restlessness are controlled with bromide 
of potassium, or sodium combined with chloral hydrate. The use of 
morphine is indicated in cases in which the chloral and bromides are 
ineffectual. Complicating endocarditis and pericarditis are treated 
as when primary. 

FORMS OF TIC. 

(Tidbit Movements or Spasms.) 

This affection is mentioned in this place to emphasize the impor- 
tance of sharply differentiating its forms from true Sydenham's 
chorea. Tic is denned by Gowers as a habitual and conscious con- 
vulsive movement of one or more of the muscles of the body, repro- 
ducing some reflex or automatic movement normal to the individual. 
Osier has classified the forms of tic. There is first the ordinary 
form, in which young people or children develop a spasm of a group 
of muscles, generally of the face. Children do not have the form 
known as idiopathic spasm of adults in which the lower extremities 
are involved. There is contraction of a group of facial muscles, such 
as the orbicularis or the muscles about the nose. There are other 
forms of tic in which mental disturbances and explosive utterance of 
words or syllables are prominent features. If the words are of an 
obscene character, the condition is called coprolalia. In other cases 
the patients repeat words or sentences (ecliolalia). The so-called 
laryngeal barks of a hysterical nature are, according to most observers. 
to be classified as forms of tic, and not as laryngeal chorea. 

There is a fourth class, which includes those cases in which the 
subject before proceeding to any definite act, such as writing, feels 
impelled to blow on the fingers, pinch the nose, or strike the head or 
thorax. These actions may be regarded as harmless tricks. In 
another form of tic the patients feel impelled to touch objects, such 
as the floor or wall (delire de toucher of French writers). 



832 DISEASES OF THE NERVOUS SYSTEM. 

RHYTHMIC MOVEMENTS OF THE HEAD ASSOCIATED WITH 

NYSTAGMUS. 

(Head-nodding ; Spasmus Nutans; Gyrospasm.) 

Nystagmus alone is quite frequently observed in infancy and 
childhood. 

Rhythmic movements of the head associated with nystagmus con- 
stitute an uncommon affection. 

The derangement is functional and occurs in poorly nourished 
and rachitic infants whose nerve resistance is diminished. The 
majority of cases give a history of some preceding illness, in the 
course of which the infant has suffered from convulsions. The 
mothers may be of a nervous temperament. The phenomenon which 
at once attracts attention is a rhythmic oscillation of the head in a 
horizontal or vertical direction, or both. On close examination it 
will also be noticed that the eyes have a horizontal, vertical, or oblique 
form of nystagmus. Ebert, Cahen, Caille, Gee, Hadden, and Lewi 
have studied these cases. Lewi reported some cases from my clinic. 
The ages of the infants ranged from three to eighteen months. The 
movements were augmented when the infant focused some attractive 
object. 

The nystagmus, if not marked, may be made apparent by holding 
an object to the right and upward for the infant to focus. Lewi as 
well as Caille found that the nystagmus ceased when the infant was 
blindfolded. In one case the movements continued when the infant 
was in the recumbent posture. The eye and head movements were 
not synchronous. As a rule the eye movements were the more rapid. 
These observers did not agree with Hadden in finding that forcible 
restraint of the head stopped the nystagmus. I have been accus- 
tomed to see a number of these cases yearly. Some of the infants 
are quite bright and well nourished. This statement agrees with that 
which Thomson recently made. Three-fourths of the cases are under 
the age of twelve months (Thomson). 

Etiology. — The etiology of the affection is obscure. It is usually 
coincident with the period of dentition, but may appear as early as 
the third month. Some of the infants live in dark, squalid quarters, 
and the affection has been attributed to eye-strain caused by the in- 
fant's attempts to fix a light as it lies in its crib. This theory would 
make the affection appear similar to that frequently seen in miners 
(Magnus). Some of the patients that I have seen lived in well- 
lighted quarters. 

Rachitis was present in most of my cases. Thomson's expe- 
rience was similar. Henoch gives a physiological explanation of the 
combination of nystagmus with the rotary movements of the head. 



HYDROCEPHALUS. 8 3 3 

by pointing out that the root nuclei of the nerves of the muscles of 
the neck and throat which rotate the head are adjacent to the ocular 
nuclei, and that any irritation of one set of nuclei may affect the 
other. This explanation has been generally accepted. 

Treatment.- — The cases as a rule recover. They are given outdoor 
air, correct food, and a general course of treatment for the rachitis. 
Phosphorus is given as in rachitis. I have also prescribed the bro- 
mides of potassium and sodium, grains v (0.35) three times daily. 
The cases certainly improved in time. The blindfolding suggested by 
Caille only stops the rhythmic movements of the head temporarily. 

HYDROCEPHALUS. 

(Dropsy of the Brain.) 

Hydrocephalus or dropsy of the brain is an abnormal accumula- 
tion of fluid in the subdural space, or in the ventricles of the brain. 
In the former case there is external, in the latter internal hydroceph- 
alus. Hydrocephalus may be acute or chronic. It may also be con- 
genital, secondary, or primary. The last-named form occurs in adult 
subjects (Delafield). Acute hydrocephalus is described under the 
caption of Meningitis Serosa. 

Congenital Internal Hydrocephalus. — The accumulation of fluid 
begins in utero. The quantity at birth may be small and may after- 
ward increase. It may be large enough at birth to obstruct delivery. 

Etiology. — The causes of the condition are unknown. Alcohol- 
ism, syphilis, and tuberculosis of the parents have been regarded as 
predisposing causes, but infants thus affected may be born of per- 
fectly healthy parents. Sometimes several infants with this malady 
are born to one mother. 

Morbid Anatomy. — The quantity of fluid accumulated in the ven- 
tricles varies. The fluid is perfectly clear and has a specific gravity 
of from 1001 to 1009. It contains a trace of albumin and some- 
times urea, sodium chloride, and cholesterin. The weight may reach 
twenty-seven pounds. The fluid distends the lateral ventricles, the 
third and fifth ventricles, and the fourth to a less degree. The cen- 
tral canal of the cord may be dilated (Delafield). The corpus callo- 
sum is displaced upward. The thickness of the cerebral substance 
may be reduced to a few millimetres. The convolutions may be 
obliterated, as may also the basal ganglia. The aqueduct of Sylvius 
is dilated. The white matter of the brain suffers most. The mem- 
brane of that organ may be normal. The ependyma may be thick- 
ened and granular. 

Symptoms.- The symptoms are the gradually increasing size of 
the head and the development o( idiocy and paralyses as a result of 



834 DISEASES OF THE NERVOUS SYSTEM. 

internal pressure on the nervous structures. The cranium enlarges 
so that it becomes disproportionate to the face, which remains small. 
There is bulging of the occipital and frontal regions. The orbital 
plates take an oblique direction, causing the eyes to assume a pecu- 
liar stare (Fig. 189). The sclera is seen exposed above the cornea. 
The eyes are directed downward and are only partially covered by 
the eyelids. The sutures are forced apart and the fontanelles are 
widely open. The anterior fontanelle bulges and pulsates visibly. 
The cranial bones may here and there show areas of thinness resem- 
bling those seen in craniotabes. The lambdoid suture is flattened 
and the greatest diameter is across the temples. The head may 
attain an enormous size, the child being unable to hold it upright. 

Fig. 189. 




Congenital internal hydrocephalus. Infant, nine months of age. 

The hair is scanty and dry. There may be strabismus, palsies, con- 
tractures, and convulsions. The eyes may not be on a level. Blind- 
ness may result. When the disease is progressive, idiocy develops. 
The children are very weak. 

Diagnosis. — Hydrencephaloid or spurious hydrocephalus is a con- 
dition which supervenes in acute exhausting states, such as that which 
follows diarrhoeal diseases. There is neither bulging of the fonta- 
nelles nor enlargement of the head. The fontanelle is depressed and 
the eyes are sunken. In certain forms of rachitis which are accom- 
panied by craniotabes and cranial bosses over the parietal and frontal 
bones, there is frequently a very mild form of hydrocephalus. This 
condition is rarely progressive. It may be distinguished from true 



HYDROCEPHALUS. 835 

congenital hydrocephalus by the absence of progressive enlargement 
of the skull. The sutures may be patent, especially that between the 
parietal and frontal bones. The signs of rachitis are present else- 
where, and the children are, in contrast to the semi-idiotic subject:-; 
of hydrocephalus, very bright. 

In differentiating congenital internal hydrocephalus from the 
external form the history is of great value. External hydrocephalus 
appears at birth and is not accompanied by bulging of the frontal 
and occipital bones. Mental deficiency is present from the outset. 
Late in the disease it may be impossible to distinguish between the 
two forms. A form of cranial syphilis is mentioned by Gowers as 
causing cranial enlargement, which, however, is never so marked as 
in congenital hydrocephalus. 

The diagnosis of congenital chronic internal hydrocephalus rests 
on the progressive enlargement of the cranium, the bulging in the 
occipital and frontal regions, and the flattening across the lambdoid 
suture. Acquired hydrocephalus rarely appears before the tenth 
month (Ireland). 

It is sometimes of interest to distinguish at autopsy between the 
congenital and acquired forms of hydrocephalus. Meynert has shown 
that in congenital hydrocephalus the lateral ventricles are dilated in 
their long diameters ; the posterior horn is dilated, so that it reaches 
within a few millimetres of the cranium. Acquired hydrocephalus, 
on the contrary, usually dilates the ventricles in their vertical and 
cross diameters. 

Prognosis. — Hydrocephalus is one of the most fatal nervous affec- 
tions. There are mild forms in which the accumulation of fluid 
ceases after a certain time and recovery takes place, the intelligence 
being either slightly weakened or normal. In some cases the enlarge- 
ment continues and death ensues from marasmus. In other cases the 
head becomes of enormous size ; the increase of fluid ceases ; the f on- 
tan elles and sutures close •; the unfortunate subjects have an enormous 
ossified skull, which they are unable to hold upright. They are par- 
tially idiotic or imbecile. They often, however, have a slight degree 
of intelligence, and may recite lessons, but are helpless in every way. 

Treatment- — The treatment of congenita] interna] hydrocephalus 
is alone of interest to the physician. The condition is hopeless. 
The injection of solutions of iodine (Morton's fluid) has been tried 
with doubtful results. I have had 2 eases in which the ventricles 
were aspirated, fluid was withdrawn, and the head bandaged. The 
operations were performed by an experl under antiseptic precautions. 
In neither case was the course of the disease affected. The thud 
reaccumulated. Both patients died. 1 have performed lumbar 
puncture on several cases, repeated a1 short intervals without perma- 



836 



DISEASES OF THE NERVOUS SYSTEM. 



nent benefit. In one ease the temperature rose to 108° E. (42.2° 
C), C hey ne- Stokes respiration set in, and the patient died. 

Cases in which Keen, of Philadelphia, inserted a permanent 
drain did not give encouraging results. Pott had an equally discour- 
aging experience with that mode of treatment. Iodide of potassium 
administered internally is of doubtful value. In estimating the re- 
sults of treatment, it should not be forgotten that a small percentage 
of cases cease to progress at a certain stage of the disease, and make 
a tolerably fair spontaneous recovery. 

External Hydrocephalus. — External hydrocephalus may be ac- 
quired or congenital. If congenital, it follows an intra-uterine 

Fig. 190. 




External hydrocephalus. (Author's case.) 



pachymeningitis or may take place because of the rudimentary state 
of the cerebrum (hydrocephalus anencephalique). External hydro- 
cephalus may be acquired, in which case it follows a pachymeningitis 
interna hemorrhagica or is the result of a meningitis in infancy. 
The congenital form of external hydrocephalus is very rare. Bokai 
records a case in an infant nine months of age. There was an accu- 
mulation of fluid between the dura and pia mater. Both membranes 
and the falx were thickened, but there were otherwise no signs of 



AMAUROTIC IDIOCY. 837 

inflammation. The infant had spastic symptoms. The diagnostic 
points in these cases are the uniform enlargement of the head and the 
bulging, especially in the temporal region. The axes of the eyes 
remain normal, the condition of those organs differing in that respect 
from that seen in internal hydrocephalus, in which they arc depres 
downward. There may be slight exophthalmos. In Lewis; Smith's 
case the axes of the eyes were normal. 

In some cases of external hydrocephalus the head attains an 
enormous size. The disease cannot then be distinguished from the 
chronic internal form. In one of my cases external hydrocephalic 
followed meningitis. The head was uniformly large, the bulging 
over the temporal region being marked. The axes of the eyes were 
normal. The intelligence was low. 

In some cases of external hydrocephalus there is a slight internal 
hydrocephalus. 

AMAUROTIC IDIOCY. 

(Family Idiocy — Sachs.) 

This disease was first described by Warren Tay, an English ocu- 
list, in 1881. Among other symptoms, he noticed peculiar changes 
in the fundus of an infant suffering from the affection. We owe the 
more extensive study of the affection to the American neurologist 
Sachs, who described his first case in 1887, not knowing that Tay and 
Kingdon had previously published theirs. Sachs has collected 27 
cases in the literature, his own cases being included in the number. 
I have published 2 cases and have since seen 25 cases. 

Etiology. — The etiology of the affection is still unknown. Alco- 
holism and syphilis do not appear to be very closely connected with 
its occurrence. It appears to run in families. Frequently two or 
more children in a family are affected. 

There is certainly a so-called neuropathic predisposition. It is 
a disease which affects more frequently children of the Jewish race : 
thus of 86 cases collected by TIerveroch in 1904, 61 belonged to this 
class. 

Course. — The course of the disease is slow and progrediant. There 
is the gradual beginning in apparently healthy children. In the 
cases thus for reported there has been no neglect in the hygiene and 
many if not most of the infants have been breast-fed. 

Forms. — There are now two well-recognized forms of the affec- 
tion. The infantile form affects infants from the third month of 
infancy and results in their death about the end o( the second or the 
third year of childhood. The juvenile form has been described by 
Iligier, Freud, Spielmeyer, and Yogt. It affects children from the 



838 DISEASES OF TEE XEEVOVS SYSTEM. 

sixth to the fourteenth year and like the infantile form is slowly 
progressive, leading to marasmus and death. The symptomatology 
and morbid anatomy of both forms are strikingly similar, with a dif- 
ference which will be pointed out later. 

Morbid Anatomy. — The morbid anatomy of amaurotic idiocy is 
certainly unique in the fact that all cases show the same changes and 
these are distributed throughout the whole nervous system; The 
nerve-cells are most affected and the changes are such as to stamp 
the disease an entity in neuropathology. There is not a normal cell 
to be found in the whole nervous system. Tay and Kingdon, Sachs, 
Van Giesen, Hirseh, Sehaffer, and Vogt have studied these changes 
and their results correspond in the main. There is a degeneration of 
the ganglion cells throughout the gray matter of the brain and cord. 
This cousists in a swelling of the cell and an extraordinary trans- 
parency and pallor of the cell-body. The form of the cell is changed 
into an ampulla-like mass, the nucleus of the cell is displaced toward 
the periphery of the body and the Xissl granulations have almost 
entirely disappeared. In some cells a few granules are left in the 
cell-body. 

The general characteristics of the nerve-cell are lost ; the swelling 
of the cell has increased its volume several times. There is chromol- 
ysis. In the final stage of the degeneration the cell does not show 
any nucleus. It is pale and colorless, the nucleolus alone is indi- 
cated and the original form of the cell is distorted. There is destruc- 
tion of the dendrites and breaking off and degeneration of the axis- 
cylinder process. The axis-cylinder may show some intact fibrillse; 
the dendrites show some fibrillation, but only in spots. The den- 
drites are much swollen. The glia shows a marked proliferation of 
cells and fibres. The pia, connective tissue, and bloodvessels show 
nothing abnormal. The above changes are seen in the brain and 
cerebellum and in the cord and medulla oblongata. The greatest 
changes are found especially in the cells of the anterior and antero- 
lateral horns of gray matter of the cord. 

Symptoms. — The symptoms are divided as follows: (1) Psy- 
chical disturbances tending to complete idiocy. (2) Weakness, 
resulting after a time in complete paralysis. (3) A normal, dimin- 
ished, or increased state of the deep reflexes. (4) Increasing blind- 
ness with pathognomonic changes in the region of the macula lutea 
(Tay and Kingdon' s spot), with optic neuritis. (5) Marasmus. 

The history of all the cases is practically the same. The infant 
is normal at birth. After from two to eight months, it is found to 
be indifferent to its surroundings. The mother notices that the 
infant who has been bright begins to lose interest in the surroundings. 
She will say that from the third month on she noticed that the infant 



AMAUEOTIC IDIOCY. 839 

no longer held up its head and that this disability has gradually 
become more apparent. The head falls backward when the infant 
is sat up. The children do not notice objects any more; they nurse 
automatically and start when there is any noise in their immediate 
vicinity. 

Many of the infants cry constantly, at the same time making 
automatic facial grimaces. The lower extremities are weak and may 
exhibit complete paralysis (diplegia). In other cases, there may at 
intervals be a spastic rigidity of the lower extremities, alternating 
with a lax condition. Convulsions are absent or may occur occasion- 
ally. The deep reflexes may be normal or diminished. In the 
spastic cases they are increased. After the first year the infants 
become totally blind and completely idiotic. They finally become 
marantic, and die after the second year with the symptoms of ad- 
vanced infantile atrophy. Occasionally there are nystagmus, stra- 
bismus and hydrocephalus. Deafness supervenes in many cases. 
The electrical contractility of the muscles may be normal or, as in 
one of my cases, diminished. 

Ocular Changes.- — The changes in the fundus of the eye described 
by Tay and Kingdon have been confirmed in the cases of Sachs, 
Roller, and the writer. They are invariably present at some period 
of the disease, but may only appear late, as in the case of Koller. 
Once present, they fix the diagnosis absolutely. The appearances 
consist of a cherry-red spot on a diffusely white area at the region of 
the macula lutea. Optic neuritis is also present toward the close 
of the disease. 

Diagnosis. — Diagnosis is not difficult after a study of the symp- 
toms. If an infant is brought to the physician with a history of 
good health and intelligence up to a certain time, after which weak- 
ness and loss of interest in its surroundings set in, with inability 
to hold the head upright, the fundus of the eye should be examined. 
If Tay-Kingdon's spot is found, the diagnosis is fixed. I have lately 
seen a number of cases in which the spastic symptoms were predomi- 
nant. There were idiocy, increase of reflexes, complete or total 
blindness, and hyperacuity. I have watched infants with these 
symptoms for a long time and failed, even with expert aid, to find 
Tay-Kingdon's spot. In these cases there was probably a birth palsy. 

The Juvenile Form. — The juvenile form o( amaurotic idiocy is 
also a family disease. It affects several members of a family group 
in the same manner as the infantile type. It begins at the sixth to 
the- fourteenth year of childhood. The onset is also gradual. The 
first symptom is an increasing blindness, which in the course 
months results in a total blindness due to an optic neuritis. The 
patients lese interest in their surroundings, forget what they have 



840 DISEASES OF THE NEEVOUS SYSTEM. 

learned in reading or writing, take less and less care of themselves, 
lose their usual spirits, soil themselves and finally lose their power 
of speech and become absolutely imbecile and paralytic. The paral- 
ysis may be flaccid or spastic. They lie for a long time moribund 
and finally pass into a marantic condition and die. On the whole 
the picture is much the same as the infantile type with the exception 
that in the juvenile form of amaurotic idiocy the cherry-red spot of 
Tay-Kingdon is not seen in the fundus of the eye, but instead there 
are the changes due to a progressive optic neuritis. 

Prognosis. — The prognosis of both forms of amaurotic idiocy is 
fatal, the infantile before the second or third year and the juvenile 
form after a year or more of illness. 

TUMORS OF THE BRAIN. 

Fully 50 per cent, of the brain tumors in infancy and childhood 
are tuberculous; gliomata and sarcomata are next in order of fre- 
quency. Cysts are secondary to a hemorrhage or embolism. They 
may remain stationary for a long period, and then increase in size 
and cause symptoms. Males are affected twice as frequently as 
females ; two-thirds of the cases in male subjects are cases of gliomata 
and tubercle. Tumors are rare in the first six months of life. The 
largest number occur in the first decade. 

Location. — The medulla is rarely the seat of tumor. The cere- 
bellum is most frequently involved (50 per cent, of the cases, Ger- 
hardt, Peterson). The pars centrum ovale and basal ganglia are 
the parts next most frequently affected. 

Etiology. — The role of traumatism is not clearly understood. 
Gliomata are due to a proliferation of the neuroglia. Tubercle and 
sarcomata are secondary to foci elsewhere. Carcinoma is rare. In 
some cases of that growth the orbit is a focus of infection. 

Symptoms. — Symptoms of pressure and irritation vary with the 
location of the tumor. A small but rapidly growing tumor will 
cause more pronounced symptoms than a large tumor of slow growth. 
Interference with the blood-supply and an increase in the quantity 
of fluid within the ventricles of the brain will cause the symptoms 
to vary. 

Gexerae Symptoms. — Headache. — This may in cortical and 
meningeal tumors be intense. It is of a boring, gnawing character, 
and is referred to the region of the tumor. Tumors in infants may 
attain great size previous to ossification of the skull. The bones of 
the skull are pushed apart and the sutures opened up. There is very 
little pain. Sleeplessness and restlessness, emaciation, and cerebral 
excitement are marked. 



TV MOBS OF THE BBAIN. 841 

Nausea and Vomiting. — Nausea and vomiting arc prominent 
symptoms and persist for a long time. The vomiting is projectile 
and occurs independently of the ingestion of food. 

Vertigo. — Vertigo is common and occurs with every change in the 
position of the head. It is a common symptom in tumors of the pons 
and cerebellum. 

Convulsions. — These may be localized or general. They occur 
when the cortex and motor areas are invaded, and eventuate in epi- 
lepsy of the Jacksonian type. In this form of epilepsy, the attack 
begins in the head or arm corresponding to the area of irritation, and 
subsequently becomes general. 

Optic Neuritis. — Optic neuritis and optic atrophy are important 
symptoms of intracranial tumor, but are not always present. When 
tumors are situated at the base of the brain, the symptoms appear 
early and are due to pressure on the chiasm. Optic neuritis is either 
double or more pronounced in one eye. 

Pulse and Respiration. — The pulse and respiration present no 
characteristic features. They show irregularities in rate. Respira- 
tion is affected only toward the close of the affection. 

Symptoms Dependent on the Location of the Tumor. — Cor- 
tical tumors in or near the motor areas cause convulsive seizures, 
which occur from the outset. Subcortical tumors will at first cause 
paralysis and, as they encroach upon the cortex, convulsions. With 
invasion of the cortex there are, in addition to convulsions with sub- 
quent epilepsy, intense headaches. Tubercle, glioma, and gumma 
occur near the surface. Cysts and sarcoma are more deeply situated. 

Frontal Lobe. — The tumors situated in the frontal lobe rep-ion 
cause stupidity and other marked changes in the degree of intelli- 
gence. There will be a perversion of the sense of smell, salivation. 
and also the drooling seen in idiocy. If the third frontal convolu- 
tion is affected, there will be motor aphasia associated with agraphia 
— a rare condition in childhood. Tumors of the motor area will in 
the earlier stages cause cortical irritation, manifested in convulsive 
twitchings in the parts first paralyzed. There may be slight sensory 
or motor disturbances in an upper extremity and an occasional 
twitching of the arm, forearm, or thumb. 

Parietal Lobe. — The tumors of the parietal lobe cause sensory 
changes in the limbs of the opposite side of the body (Dana). If 
the white substance is the seat of tumor, there may bo hemianopsia : 
Wernicke's centre for conjugate movement of the eyes may bo affected 
if the tumor is situated in the inferior part of the parietal lobe. 

Occipital Lobe. — Tumors oi' the occipital lobe cause homonymous 
hemianopsia with or without epileptiform convulsions, the latter 
being probably duo (o invasion oi' the cortex. 



842 



DISEASES OF THE NEEVOUS SYSTEM. 



Temporosphenoidal Lobe. — Tumors of the temporosphenoidal 
lobe cause impairment of hearing on the side opposite to the lesion 
and sensory aphasia. The patient is able to speak, but cannot under- 
stand what is said or repeat spoken language. 

Ganglia. — In tumors of the ganglia there is involvement of the 
internal capsules. There are no convulsions and none of the choreic 
and athetoid movement seen in cortical tumors. 

Cms Cerebri. — Tumors of the cms cerebri cause paralysis of 
motion and sensation on the opposite side of the body, and oculomotor 
paralysis, ptosis, and paralysis of the muscles of the eyeball, except 



Fig. 191. 




Pons tumor, showing nuclear palsies. Left abducens paralysis. 

the external rectus and superior oblique. There will be paralysis of 
the sphincter iridis and ciliary muscle. There may be paralysis of 
both sides of the body, double ptosis, and double oculomotor symp- 
toms. The majority of cases are at first unilateral, later becoming 
bilateral. Loss of pupillary reflex, nystagmus, and cerebellar ataxia 
point to involvement of the corpora quadrigemina. 

Pons. — Tumors of the pons cause unilateral or bilateral symp- 
toms. There is hemiplegia or double hemiplegia with paralysis of 
the cranial nerves. There is paralysis of the third, fifth, sixth, sev- 
enth, and eighth nerves of the side of the lesion, with hemiplegia of 
the opposite side. There may thus be paralysis of the external rectus 
with facial palsy and impairment of hearing on one side. If the 



PLATE XXXVII 







Birth Palsy, Apoplexia Neonatorum. (McNutt.) Shaded portions 
show the location of the hemorrhage. 



INFANTILE CEIIEBIIAL PALSY. H 13 

nucleus of the sixth nerve is involved, there will be paralysis of con- 
jugate movement of the eyes toward the side of the lesion, while if 
it is not affected there will be only external rectus palsy of the side 
of the lesion not affecting conjugate movement of the other eye. 

Medulla. — Tumors of the medulla manifest themselves in bulbar 
symptoms. There will be paralysis of the glossopharyngeal, vagus, 
spinal, accessory, and hypoglossal nerves. Thus there are unilateral 
or bilateral paralysis of the arms or legs, difficult deglutition, and 
disturbances of the respiratory movements and of cardiac action. In 
addition there will be spasm of the sternomastoid and trapezius mus- 
cles, and paralysis of the tongue, with atrophy, vomiting, polyuria, 
and glycosuria ; optic neuritis occurs early, and there is severe occip- 
ital headache. Gummata in this region are not uncommon. 

Cerebellum. — Tumors of the cerebellum, which are usually of the 
solitary tuberculous form, are the most important intracranial growths 
in children. There will be occipital headache, vomiting early in 
the disease, and cerebellar titubation due to encroachment upon the 
middle peduncle. Vertigo is severe. The sixth, seventh, or eighth 
cranial nerves may be involved. There may be bulbar symptoms. 
Paralysis of the external rectus is very common in these tumors. 
Optic neuritis may be present. 

INFANTILE CEREBRAL PALSY. 

(Spastic Hemiplegia; Diplegia; Paraplegia.) 

Forms. — Cerebral infantile palsy may originate in utero, or a 
short time after the birth of the infant. It is then called cerebral 
diplegia, birth palsy or Little's disease. It may occur any time after 
birth, most frequently during the first three years of life. The palsy 
then has an acute onset and takes the hemiplegic form and is called 
hemiplegic infantile cerebral palsy. These two forms of cerebral 
palsy have much in common both as to pathology and symptomatology. 

Cerebral Diplegia, Little's Disease. — This affection, first brought 
to the notice of the profession by Little, was also studied by MoNutt. 
To the latter we owe the demonstration of the cause of the disease. 
Under the title Apoplexia Neonatorum she demonstrated that in easy 
as well as prolonged labor and instrumental deliveries hemorrhage 
on the surface of the brain was the first step in the clinical and patho- 
logical history of these cases ( Plate X XX VII.). Cerebral diplegia 
is a form of bilateral paralysis dating from birth or noticed soon after 
birth or as the result of some infections disease as late as the sixth 
month after birth (Henoch), or even the third year o( life (Starr). 

Etiology. The etiology is divided into first, those cases in which 
the causes are traced to intra-uterine life and are connected with 



844 DISEASES OF THE NEEVOUS SYSTEM. 

disturbances in utero due to traumatism to the mother during preg- 
nancy, illness or psychical disturbances of the mother, and syphilis. 

Second are the causes which act on the child during labor, difficult 
parturition, abnormal position of the child, asphyxia, cither through 
prolonged labor or abnormal position of the cord, or premature de- 
tachment of the placenta, and prematurity of the infant or labor. 

Third, there are the etiological factors acting on the infant after 
birth, such as the infectious diseases. Such cases have been observed 
by Henoch in an infant who six months after birth developed diplegia 
after measles. 

Symptoms. — MclSTutt described the symptoms referable to the cere- 
bral hemorrhage in cases of diplegia. They consist of disturbances of 
respiration more or less marked, partial or complete loss of conscious- 
ness and convulsions. The latter may be general or involve half of 
the body. Many of such infants die soon after birth. If they live, 
they show signs of asphyxia neonatorum. In such cases even after a 
normal delivery, the infant breathes irregularly, or ceases to breathe, 
cries feebly and then lapses into a quiescent state with shallow and 
irregular breathing. It may be cyanosed and in this state may have 
several convulsions. Other cases are born apparently well but after 
twenty-four hours convulsions and disturbed respirations appear. If 
these infants live, the subsequent clinical history is as follows : 

Diplegia, — In many cases the diplegia consists in a paralysis of 
both arms and legs or of the legs alone and is noticed soon after birth. 
The parents observe that voluntary motion is interfered with, that the 
infant is alternately rigid and lax, is not intelligent and does not 
nurse as ordinary infants do. There is hyperacusis ; the children 
start at the least sound and cry as if in fright. The reflexes are 
much increased, the trunk and extremities are rigid. In some cases 
the back is rigid and the children are unable to sit upright. There 
is difficult} 7 in nursing and some must be fed by hand. As the child 
grows, it is seen to be mentally deficient, notices objects in a vague 
sort of way, cannot talk, cannot sit on account of the rigidity, and 
en 11 not stand. If aided these children may stand, but the extrem- 
ities take a spastic position. The toes are applied to the ground 
and there are crossing of the legs and equino varus. The heels do 
not touch the ground and the children cannot balance themselves. 
Some may be able to walk, but only stiffly, aiding themselves with 
the hands ; others may walk with the aid of support, such as a cane 
or crutch. These are favorable, as many of the children are bed- 
ridden. In such cases the arms are flexed and spastic, as are also 
the lower extremities. There are constant athetoid movements, com- 
bined with chorea, both of facial muscles and extremities, and finally 
epilepsy is often developed, so that the difference in symptomatology 
between these cases and those of hemiplegia is only one of degree. 



INFANTILE CEREBRAL PALSY. 845 

The feeble-mindedness of such children and their utter helpless- 
ness is touching. They can be taught only the simplest things and 
until late in childhood they are a burden to themselves and other:-;. 
There is no marked improvement and many become easy prey to 
intercurrent affections. Optic atrophy, blindness, nystagmus, stra- 
bismus, deafness, are among the other symptoms noted in many cases. 
In some there are symptoms of bulbar involvement, such as difficulty 
in deglutition and motor disturbances of speech. 

Convulsions and epilepsy develop later on and in many cases lead 
to complete idiocy if such was not present at birth. 

Hemiplegic Infantile Cerebral Palsy (Spastic Hemiplegia). — 
Occurrence. — According to Gowers the disease is more frequent in 
females, but there is no predisposition as to sex. It is most frequent, 
according to Osier, Wallenberg, Gaudard, Lovett, Sachs, and Peter- 
sen, in children from a few months of age to the third year of life, 
when it becomes infrequent up to the tenth year. All the above 
writers report cases occurring in utero or congenital (intra-uterine 
and during parturition). 

Etiology. — The etiology of these cases is still a matter of discus- 
sion. When Striimpel proposed the theory of an encephalitis similar 
to that occurring in infantile poliomyelitis, it was for a short time 
accepted. Clinically this theory was founded on certain similarities 
between the spinal and cerebral affections. It is found that many 
of the cases follow the acute infectious diseases, especially measles 
and scarlet fever (Gowers). Cerebral palsy may follow typhoid 
fever, pertussis, pneumonia, amygdalitis, cerebrospinal meningitis, 
gastro-enteritis, and traumatism to the skull. Infection or the pres- 
ence of infectious disease cannot alone explain all the cases. Another 
view is that the convulsion at the outset of the disease causes the 
bursting of a vessel weakened by some form of degeneration (Osier) . 

Symptoms. — General Picture. — The disease occurs from the age 
of a few months to three years. There are at first in the acute stage, 
fever, convulsions, vomiting, which may extend over a period of a 
few days or weeks. During this stage or later the paralysis which 
involves the face, arm and lower extremity becomes evident. The 
paralysis, as first flaccid, soon becomes spastic with increase of reflexes 
and contractures. Disturbances of speech and aphasia are common, 
but for the most part temporary. In rare cases there occur ocular 
palsies. Tin* hemiplegia may disappear to recur or it may, as in 
most cases, remain permanent. The improvement in the paralysis 
occurs mostly in the lower extremity and is less evident in Che arm 
and forearm. With the improvement of the paralysis there appears 
the so-called post-hemiplegic chorea. The paralysis remains spastic. 
There are more or less marked disturbances of the intelligence. Later 



846 DISEASES OF THE NERVOUS SYSTEM. 

in life, varying in different cases, epilepsy, at first limited to one 
side and then general and severe, makes its appearance (Fig. 192). 

Paralysis. — The paralysis involves both sides with about equal 
frequency. It is of the spastic type. The facial muscles are in- 
volved to a mild degree; more markedly paralyzed are the muscles 
of the upper extremity, less those of the arm and least or not involved 
at all are the gluteal and abdominal group. The facial muscle is 
frequently involved in the hemiplegic form; fully in half the cases 
(Konig). It is not very marked, certainly not as much as the paral- 
ysis of the extremities. In exceptional cases the reverse is true. 

Hemiplegia. — The hemiplegia may present mixed forms of 
paralysis. The arm and forearm are more affected than the lower 
extremity. There may be apparent monoplegia of the upper extrem- 
ity with facial paralysis on the same side or athetosis or chorea of 
the lower extremity. There may be diplegia of the lower extremities 
with increased reflexes on both sides, combined with a hemiplegia, or. 
as Lovett points out, a hemiplegia may result in subsequent spastic 
paraplegia. 

Contractures, Reflexes, Position, and Gait. — The arm is closely 
applied to the trunk, the forearm is held in semi-pronation and flexed 
at a right angle against the arm. The elbow is carried close to the 
body. The hand is bent to the ulnar side and the fingers are flexed 
more or less into the hollow of the hand, covering the thumb. The 
lower extremity is slightly rotated inwards and the leg flexed slightly 
on the thigh with plantar flexion of the foot. The toe is pointed 
inward, giving the equinovarus position to the foot. In the majority 
of cases the great toe is over-extended at right angles to the meta- 
tarsus (Gaudard). The contractures which are thus pictured may 
appear in utero, or immediately after the onset of the paralysis, or. 
what is common, the paralysis is first flaccid and then becomes spastic 
with contractures, or the contractures at first may be evanescent and 
not reappear, or contractures may be absent, especially in congenital 
cases. Contracture, if once present, fixes the extremity so that it 
cannot be straightened, even under narcosis. Sometimes at the height 
of the paralysis the contracture may relax or relax in one extremity 
and persist in another or athetosis may be present in the hand, while 
contracture exists in the arm and forearm, or chorea may be present 
in one extremity and contracture in another (Tig. 193). 

The patellar reflex is increased as a rule but it may be absent in 
the presence of chorea or much diminished. In severe spastic paral- 
ysis there is bilateral increase of reflex. 

The gait is dependent chiefly on the conditions present. In sim- 
ple hemiplegia the gait is that seen in hemiplegia of the adult. If 
the foot is badly affected in equinovarus the children walk practically 



INFANTILE CEBEBBAL PALSY. 



8 \ 



on the toes of the affected limb. If the opposite side is spastic, the 
gait is that of ataxia and spastic paraplegia. 

Ocular Palsies. — The ocular palsies which may be present in 
infantile cerebral palsy include oculomotor paralysis; ptosis, on the 
side of the paralysis, and temporary abducems paralysis (Freud and 



Fig. 192. 



Fig. 193. 




Cerebral palsy, left side hemiplegic, 
dating from early infancy. 




Cerebral Daisy, left side 
hemiplegic, dating from later 
childhood. 



Eie). Homonymous lateral hemianopsia has been described by 
Freud in 1889. It is rare but it occurs as Sachs lias found it in S 
cases. Freud regards the hemianopsia as of cortical origin. 

Sensibility. — Sensibility is somewhal though not markedly dis- 
turbed in children. There is slightly marked hemianesthesia. The 



848 DISEASES OE IEE NEBVOU8 SYSTEM. 

most irksome are pains in the extremities traceable to the muscle 
conditions. The shoulder and elbow especially may be the seat of 
these pains. 

Aphasia. — Aphasia may be present either as a true aphasia or 
there may not be a true aphasia, but the children are slow to learn 
spoken language. Aphasia, however, is not as a rule a permanent 
symptom. Aphasia may exist in either right- or left-sided hemi- 
plegia. The aphasia is therefore an ataxic motor aphasia and in 
lesions of the speech-centre on the left side, the right hemisphere in 
children may act in a compensatory manner and an improvement in 
the aphasia results. 

Post-he mi pie gic Disturbances. — Post-hemiplegic disturbances of 
motion take place in the paralyzed members and are of three classes 
in the presence of voluntary intended acts. The voluntary motion 
may be attended by spastic contraction either in the presence or 
absence of contracture of the extremities. There is ataxia, that is. 
after the impulse is conveyed to a group of muscles, there is hesita- 
tion before the intended act is accomplished. Finally we have in the 
paralyzed members so-called post-hemiplegic chorea as in cases of 
ordinary chorea on attempts to use the paralyzed muscles. 

'"' Chorea/'' — After the completion of the stage of complete paral- 
ysis, we have in almost all the cases in which spastic ataxia accom- 
panies voluntary motion a further development of spontaneous move- 
ments in the form of " chorea " independent of the will. On the 
appearance of chorea in the paralyzed members, the contractures dis- 
appear, but motion and voluntary use of the limb is more than ever 
hampered by the choreatic motion. Chorea may affect one or both 
paralyzed members, and may appear at the time of the contracture 
or later on. 

Athetosis. — Added to the chorea is athetosis. This consists in 
slow, involuntary movements of the paralyzed part, producing flexion 
and extension of the fingers and hand, of the elbow and shoulder, and 
more rarely of the foot and muscles of the face. It is increased by 
voluntary motion of the paralyzed or healthy part, or emotional 
f-xcitement. This athetosis was first described by Hammond, and 
i s now recognized to be due to a lesion of the brain cortex. It may 
appear early or late in the disease. It is a frequent symptom. 
Athetosis differs from the chorea in that it is a rhythmic motion in 
contrast to the changeable sudden motion of chorea. 

Trophic Disturbances. — Trophic disturbances occur in infantile 

cerebral palsy and affect the soft parts and the bones of the skull 

and extremities and joints. There are thickening and irregularities 

i th - - i "he skull. The muscles of the face and extremities 

are slightly atrophic. The electrical reactions of muscle in the par- 



INFANTILE CEREBRAL PALSY. 849 

alyzed members show no change except in cases of very long stand- 
ing, where there is a change in the muscular reactions. There is 
also a retardation in growth of bone and muscle. 

Epilepsy. — Epilepsy appears in most cases of infantile hemi- 
plegia as a closing complication. It may appear after the lapse of 
several years or may in unusual cases come on after the initial con- 
vulsions. As a rule the more recent the case the less likely there is 
to be epilepsy, so that the first two years of life are free from it. The 
frequency of this complication varies with the cases studied. Thus 
Gowers gives the frequency as 66 per cent, in his cases, while Gaudard 
found it in 13 per cent., and Sachs in 50 per cent. 

At first the epileptic seizures are not as outspoken as in true 
epilepsy. The aura is more distinct and gives warning in time, the 
initial cry is wanting, the biting of the tongue less frequent and coma 
and delirium do not follow the attack. While this is so at first, the 
subsequent course is such that ultimately there is no difference be- 
tween these epileptic seizures and those of true epilepsy. The condi- 
tion of the mind suffers in all cases of hemiplegia, from mild states 
of weakened intelligence to total idiocy. The epileptic seizures con- 
tribute still further to intensify the injury to the psychic sense. 

Course.- — It will be seen from the above that the eases of infantile 
cerebral paralysis or hemiplegia have a certain course : the prodromal 
stage, the paralysis with contracture, the chorea, and finally the 
epilepsy. All cases do not develop chorea and epilepsy, nor does the 
paralysis show an equal intensity in all cases. Some show an evanes- 
cence of paralysis ; in others the paralysis is very mild, without 
chorea or epilepsy, and lastly cases occur in which in the stage of 
epilepsy the paralysis disappears, so as to mislead into a diagnosis of 
primary epilepsy. In other instances the epileptic seizures when 
they appear and as they do dominate the clinical picture may miti- 
gate and disappear after short or long intervals. 

Morbid Anatomy. — Prenatal Cases. — There is porencephaly. Half 
a hemisphere, an entire hemisphere, or both hemispheres may be im- 
perfectly developed. There are also certain defects in the cerebral 
hemisphere to which is applied the term " Agenesis Corticalis." 
That is to say, there is imperfect development of the cortical gray 
cells, particularly those of the pyramidal type. The agenesis may 
extend throughout all parts of the hemispheres. 

Birth Palsies. — The principal lesion is meningeal hemorrhage 
(McNutt). This may occur in areas over the cortex 3 or at the base 
of the brain. There may be a diffuse hemorrhage over the whole 
cortex of one hemisphere. The extravasation is. as a rule, most pro- 
fuse over the motor area. 

r>4 



850 DISEASES OF THE XEBFOUS SYSTEM. 

Acute Palsies. — In these there are found embolism and throm- 
bosis, or hemorrhage, the latter occurring mostly at an advanced age. 
As a result there may be atrophy of the cortex, sclerosis or cyst forma- 
tions. Cysts are sometimes found later in life, there having been no 
previous symptoms (Gowers). They undoubtedly originate in in- 
fancy. Some authors (Gowers) state that embolism, others that 
hemorrhage, is the pathological condition most frequently found in 
cerebral palsies of acute origin. The cause of hemorrhage in these 
cases is still a matter of speculation. There is certainly a change in 
the bloodvessels, but whether it is the fatty change seen in the blood- 
vessels in infancy and first pointed out by von Recklinghausen, is a 
question. It may be that, given a vulnerable bloodvessel, heart dis- 
ease or any infectious disease will predispose to hemorrhage. Cysts 
are likely to be found in cases in which there is idiocy. 

Diagnosis. — Intra-uterine and birth palsies give a distinct history 
of early development. If a palsy has developed a few months after 
a normal labor, it is to be classed as possibly intra-uterine. Both 
prenatal and birth palsies are likely to be diplegic or paraplegic. As 
a rule there is mental deficiency. Paralysis may be complete, or, as 
in one of my cases, scarcely noticeable. Double athetosis is indica- 
tive of double hemiplegia, and may even take the place of paralysis. 
Choreiform movements are frequently mistaken for chorea. They 
are unilateral and combined with exaggerated reflexes and partial, 
slight, or marked paralysis. Aphasia of cerebral palsies is motor 
rather than sensory. Its presence precludes the possibility of the 
palsy's being of prenatal or of birth origin. 

The cerebral palsies are differentiated from the infantile forms 
of paralysis by the presence of spasticity, contractures, rigidity, in- 
crease of deep reflexes, and occasionally by the presence of athetosis 
and choreiform movements and epilepsy. In recent cases the absence 
of atrophy will also aid in diagnosis. 

Prognosis. — So far as prenatal and birth forms of palsy are con- 
cerned, no definite prediction in regard to the outcome can at first 
be made. Many of the cases of birth palsy die at the outset. Some 
escape with very slight paralysis. Others develop convulsions with 
subsequent epilepsy and idiocy. Contractures, diplegia, and double 
hemiplegia with spastic symptoms may develop. The acute cerebral 
forms may improve to such an extent that only slight paralysis, chorei- 
form movements, or athetosis remain. In other cases improvement 
is followed by a return of the symptoms, with convulsions and epi- 
lepsy. It is estimated that fully 45 per cent, of the cerebral palsies 
develop epilepsy, while the diplegic forms are less likely to do so. 
One convulsion is apt to be followed by others, and these in time by 
epilepsy and mental deficiencies. 



FACIAL PALSY. 851 

Treatment. — -The treatment of cerebral palsy is ultra-conservative. 
Cases of birth palsy have difficulty in deglutition. Aid in keeping 
up the nutrition of the patient may be given by spoon-feeding or 
feeding with stomach-tubes (gavage). If there are convulsions, bro- 
mides in moderate doses are administered. The infant should be 
kept perfectly quiet. In the acute cerebral cases, if hemorrhage is 
suspected, rest and the application of an ice-bag to the head are indi- 
cated. Subsequent convulsions are treated with bromides. The 
bowels are kept open with calomel. In cases in which there is slightly 
marked paralysis, massage and the various forms of hydrotherapy 
are of great utility. The faradic current has much the same effect 
as massage. If contractures and choreiform movements supervene, 
the various orthopaedic appliances are of great practical utility. 
Where indicated, they should be used in connection with judicious 
tenotomy. Surgical interference has been practised in forms of epi- 
lepsy which simulate the Jacksonian type. The results are disas- 
trous in young children, nor is permanent relief to be expected in 
older ones. 

FACIAL PALSY. 

(Bell's Paralysis.) 

Paralysis of the facial nerve is quite common in infancy and 
childhood. As in the adult, the distribution and etiology of the 
paralysis vary. 

The facial paralysis observed in infants who have been delivered 
with forceps is a pressure paralysis. It may affect the upper or 
lower branches of distribution. The prognosis of this form of paral- 
ysis is, as a rule, very good. Eecovery takes place after a few week?. 
Some cases do not thus recover ; there should therefore be some con- 
servatism in prognosis. Congenital facial palsy may occur in the 
absence of any history of traumatism or pressure. Henoch records 
such a case in a boy of ten years. There was deafness on the side of 
the paralysis, but no history of disease of the ear. 

The so-called rheumatic form of facial paralysis occurs in infants 
and children, but rarely does so before the third year, and most com- 
monly between the sixth and fifteenth years. The symptoms are the 
same as in later life (Figs. 104- and 195), 

Of greatest interest to the practitioner are t lie facial palsies 
which occur in infants and children as a result of ear disease or of 
inflammatory disease of the mastoid process. In infants a few 
months old, I have seen facial palsy due to otitis in one ear (Fig. 
196). Henoch has seen cases in infants from three to five months 
o\' age. The facial nerve is affected as it passes through the Fallo- 



8.32 



DISEASES OF TEE NEEVOUS SYSTEM. 



pian canal. Caries of the bone, pus, or swelling in the vicinity of 
the canal, will cause this form of paralysis. It is therefore a species 



Fig. 194. 




Facial paralysis, left side, rheumatic form. Girl, eight years of age. 
Fig. 195. 




Facial paralysis, rheumatic form, showing inability to close the eye. Girl, eight 

years of age. 

of pressure paralysis. There may be no distinct collection of pus in 
the mastoid cells, but, when opened up, the mastoid is found to be 



FACIAL PALSY. 



853 



filled with granulations. Temperature, tenderness, and redness over 
the mastoid should arouse suspicion. 

Bokai reports a case of retropharyngeal abscess in which the 
facial palsy, was caused by pressure on the nerve as it emerged from 
the stylo-mastoid foramen. 

Another form of facial palsy is that seen in basilar disease of the 
brain. The facial palsy seen in tuberculous meningitis and some- 
times in the non-tuberculous variety is of great diagnostic import. 
This paralysis is not always marked; it is often a very slight paresis 
with flattening of the facial muscles on one side and accompanied by 
slight widening of the palpebral fissure on the same side. In con- 
nection with this symptom, a dilatation of one pupil or slight stra- 

Fig. 196. 




Facial palsy complicating otitis. Infant, seven months of age. 

bismus is exceedingly significant of basilar affection. In other 
words, in the forms of meningitic facial palsy, the physician should 
be on the alert for changes in the contour of the face, since in many 
of these cases the patient is conscious only at intervals. In many 
cases, restlessness on the part of the patient will cause the slight 
flatness of the face or widening of the palpebral fissure to disappear. 
The patient should be watched unawares or when at perfect rest. 
The facial palsies with cerebellar tumors and tumors of the pons have 
been referred to in the section on Tumors. 

Operative facial palsy in infants and children is likely to occur 
after the radical operation on the mastoid, if the operator is not a 
thorough anatomist. 1 have fell that this accidenl could bo avoided. 
After an operation on the mastoid 1 have seen mild facial palsy, 
consisting of a very slight lagophthalmos with slighl flattening 
I he facial muscles, which disappeared within twentv-four hours. [I 



854 DISEASES OF THE NERVOUS SYSTEM. 

was possibly due to pressure on the nerve during the operation. 
Facial palsy following a mastoid operation is, as a rule, due to actual 
traumatism to the nerve, and to its partial or total destruction. The 
paralysis in such cases is permanent. Finally there is a facial palsy 
described in the article upon poliomyelitis. 

Treatment. — The treatment of facial palsy in infants and children 
is determined by the origin of the palsy, and is essentially the same 
as in the adult. 

MULTIPLE NEURITIS. 

This is an affection in which several or most of the peripheral 
nerves undergo degeneration of an acute type. The nerves affected 
are, as a rule, symmetrically distributed. 

Etiology. — The disease may be caused by the poisonous action of 
drugs, such as lead, arsenic, and alcohol. It follows the infectious 
diseases — measles, diphtheria, typhoid fever, influenza, and malaria. 
In such cases the degeneration is due to the action of bacterial 
toxins on the peripheral nerves. Cold is said to favor the onset 
of the disease. In many cases it is impossible to fix upon any defi- 
nite cause. 

Frequency. — If we except diphtheritic paralysis, affections of the 
peripheral nerves are much less common in childhood than in later 
life. It is extremely rare in early infancy, though I have seen mul- 
tiple neuritis follow measles, in which the nerves of the face, the 
eyes, the soft palate, the extremities, and trunk were involved in a 
child of fourteen months of age. When it does occur in childhood, 
there is a strong hereditary predisposition, or the morbific influence 
in the case has especial predilection for the peripheral nerves. 

Morbid Anatomy. — There is an early stage during which there are 
hyperemia and swelling of the sheaths of the nerves, which may be 
the seat of minute hemorrhages. The nuclei of the sheaths are 
enlarged. There is an increase of connective-tissue cells between the 
nerve-sheaths, and also of round and spindle-shaped cells between 
the nerve-fibers. The changes in the nerve-fibres are characteristic 
of nerve degeneration. The muscles may be the seat of parenchy- 
matous degeneration. The striation may become indistinct. In 
some cases there are also interstitial changes. 

Symptoms. — The symptoms of multiple neuritis in children are 
very characteristic. After an infectious disease, the child no longer 
walks with a steady gait, but may stumble and fall. After a time 
it is noticed that the patient does not care to stand, and the mother is 
unable to persuade it to do so. The child cries when put on its feet, 
which refuse to support it. There seems to be pain connected with 
an attempt to stand, and also on handling and pressing the muscles. 



MULTIPLE NEURITIS. 855 

Paralysis. — After a time the child does not sit upright, hut falls 
back or toward one side when put in the sitting posture. It finally 
becomes completely paralyzed. The paralysis is progressive and 
symmetrical. The child does not use the hands. The feet drop 
forward (foot-drop) and there is a very characteristic wrist-drop. 
The child lies helpless in the crib, unable to move. Some of these 
patients cry constantly as if in pain. During this time there is good 
nutrition and the appetite is good. The muscles of the trunk are 
frequently affected as well as those of the extremities. In these cases 
there is a species of paralytic lordosis when the child stands or sits 
upright. In a few cases the muscles of the eye are affected, and in 
fatal cases those of the diaphragm. 

The facial and hypoglossal nerves are rarely the seat of the dis- 
ease. The musculospiral and peroneal nerves seem, as in polio- 
myelitis, to be affected. The reflexes are diminished and finally 
disappear. The dorsum of the feet and hands is slightly affected 
with oedema. 

Sensory Disturbances. — In spite of statements to the contrary, it 
is very difficult in children and infants to elicit exact data as to the 
pain or sensory changes and their distribution. I have found evi- 
dences of pain on handling the children or attempting to make them 
stand or sit. The patients are restless at night, and cry most of the 
time, and it must therefore be inferred that they have pain. 

Course. — The majority of the c'ases make a complete or almost 
complete recovery. In a case which I watched very closely the 
reflexes were slow to return, although the child began to sit upright, 
then to stand, and finally to walk. The gait in walking was very 
peculiar. It was a sort of waddle, resembling that exhibited in con- 
genital luxation of the hips. The boy, three years of age, finally 
made a complete recovery. 

As a rule, the symptoms increase in severity for from four to six 
weeks ; they then retrograde and improvement sets in. In some cases 
the development of symptoms is rapid, the diaphragm becomes 
affected, and the children die of bronchopneumonia. If the vagus 
is affected, death occurs through cardiac failure. Diphtheritic cases 
are apt to be progressive and fatal. 

Diagnosis. — If the clinical picture is studied, the diagnosis is 
not difficult. The complete and absolute paralysis is, in its mode of 
onset and its symmetrical distribution with anatomical impairment 
of sensation of all kinds, so peculiar that it cannot be confounded 
with poliomyelitis. In the cases which I have seen the muscular 
atrophy was also less marked than in the latter disease. The very 
characteristic feature of the paralysis is its flaccidity. If the child 
is made to sit upright, the glutei muscles flare, as it were, outside 



856 



DISEASES OF THE NEEVOUS SYSTEM. 



the body-line and do not retain the tonicity of the normal muscle. 
There is nevertheless not mnch atrophy of the glutei. Landry's 
paralysis is so rare in infancy and childhood that it need not be con- 
sidered in detail. 

The pain in these cases is always marked, even in young children 
and infants. They cry when handled, and resist all examination. 

Fig. 197. 








/f Z)**S,t<i 



Multiple neuritis in a child two and one-half years of age. Shows the complete relaxa- 
tion of the glutei muscles. Recovery. 



In older children pressure on the nerve-trunk at their point of expo- 
sure underneath the skin, such as in the popliteal space or in the 
sacro-iliac groove, is exceedingly painful. The complete recovery 
in favorable cases without paralysis or paresis differentiates it from 
poliomyelitis. 

Treatment. — The treatment is palliative, since the disease is not 
only self-limited, but also tends to spontaneous recovery. The pain 



EBB'S PALSY. 857 

is relieved and the skin kept in good condition by massage. If the 
child is restless, it is treated in the ordinary way. There is no 
specific for the affection. Electricity is not recommended by those 
whose experience gives weight to an opinion. If contractures result, 
orthopedic appliances are indicated as in other paralytic diseases. 

ERB'S PALSY. 

(Obstetrical 



This form of palsy, which occurs in infants and children as well 
as in adults, is due to a neuritis caused by direct traumatism either 
to the nerves supplying the muscles of the shoulder, or as in the 
newly born infant by traction or pressure on the brachial plexus. 
Erb showed that the point injured in these cases is the spot between 
the scaleni at the exit of the fifth and sixth cervical nerve roots. 
Duchenne, Seeligmiiller, and Henoch have described these birth cases 
in infants. I have seen cases in older children which correspond to 
the adult cases. 

Symptoms. — The symptoms are very characteristic. There is 
complete paralysis of the arm on the affected side. The child ; if 
directed to raise the arm or forearm, is unable to do so. The fingers 
can be moved. Infants sometimes hold the paralyzed arm with the 
healthy one. In a few cases there seems to be pain, caused by the 
drag of the paralyzed member on the shoulder. After a time there 
is atrophy of the deltoid and other muscles about the shoulder- 
joint, which causes the bony prominences to show markedly (Plate 
XXXVIII. ). The atrophy sometimes comes on very rapidly. In 
infants and children it is impossible to reach any conclusion in regard 
to the intensity of pain and the disturbances of sensation. 

Diagnosis. — The cases should be differentiated from cerebral birth 
palsies. Apart from the electrical reaction, the absence of hemi- 
plegia or diplegia of a spastic nature with rigidity, the absence of 
increased reflex, and also of convulsions, all of which are present in 
birth palsies, will aid in the diagnosis. Later in life it may not be 
possible to determine which form is present. 

Prognosis. — The prognosis is good, but I have seen severe cases of 
obstetrical palsy which failed to recover. 

Treatment. — The treatment depends on the origin of the palsy. 
If it is obstetrical, the arm should be put in an apparatus to protect 
it from injury. After two weeks, friction, massage, and a mild 
electrical current of the faradic variety should be applied. If con- 
tractures develop later, splints should be constructed to counteract the 
tendency. On the whole, the management of the cases is based on 



858 DISEASES OF THE NERVOUS SYSTEM. 

the principles which govern the treatment of peripheral palsies. 
Later on surgical treatment by nerve anastomosis may be indicated. 

HEREDITARY ATAXIA. 

(Friedreich's Disease; Hereditary Ataxic Paraplegia.) 

This is a form of ataxia which frequently affects several members 
of the same family. Riitimeyer and Griffith collected 233 cases 
which were distributed in 107 families. In 38 cases there was a 
direct hereditary history. In the remainder there was a history of 
alcoholism, syphilis; or consanguineous marriage. Sixty-five cases 
of Gowers were distributed among 19 families. Thus there was an 
average of 3 to each family. In some families there were 10 cases. 
Isolated cases are rare, and occur, as a rule, only in children. The 
disease affects the sexes equally. Cases have occurred as early as 
the second year, and as late as the twenty-fourth, but are seen most 
frequently between the seventh and eighth years. 

Symptoms. — The onset of the disease may be gradual or abrupt. 
The first symptom is an impairment of coordination in the lower 
extremities. The patient is unsteady in walking, and stands with 
the feet wide apart. Some patients reel when the eyes are closed 
more than at other times. In other cases Romberg's symptom is 
absent. The feet show the peculiar deformity of pes cavus. The 
instep is high and the toes over-extended. The movements of the 
arms next become ataxic. The speech becomes slow and halting. 
Jerking, nodding movements of the head set in. Irritability of 
muscle is absent from the beginning. The deep reflexes may be 
present at first, but finally disappear as in true tabes. 

Nystagmus is usually present, and may be a very early symptom, 
appearing simultaneously with the ataxic symptoms. The symp- 
toms connected with the speech may come on very late in the disease. 

Optic atrophy is never present, and the Argyll-Robertson pupil 
of tabes is absent. 

Sensory disturbances, such as shooting pains, are rare, but may 
occur. There is no tendency to trophic joint-affection as in tabes. 
The sphincters are normal. 

Muscular power, although normal at first, diminishes as the dis- 
ease progresses. There is atrophy of muscle. Spinal curvatures, 
talipes equinus, and equinovarus result. The loss of muscular power 
is sometimes limited to the lower extremities. 

The mental condition is generally affected. The children are 
slow at school. Imbecility has been recorded (Gowers). 

Course. — Once inaugurated, the disease is progressive, but it may 
remain stationary at any stage for some years. The duration is 



ACUTE ENCEPHALITIS. 859 

extended over years. Gowers gives the period as ten to twelve years. 
The patients finally become bedridden, and, as a rule, die from inter- 
current disease. The anatomical changes have not as yet been com- 
pletely classified. This is due to the fact that in certain forms of 
hereditary ataxia resembling Friedreich's disease, Marie and Hoff- 
mann have described changes other than those found in typical cases 
of that affection. The changes in Friedreich's disease consist in a 
diminution in the transverse diameter of the cord and a sclerosis of 
the posterior and lateral columns, involving the pyramidal tracts. 
The neuroglia and vessels of the tracts are involved ; whether this is 
due to an arrest of development of a congenital nature has not been 
determined. 

Differential Diagnosis. — The disease should be differentiated from 
true tabes. In the latter there are the Argyll-Robertson pupil and 
optic neuritis, the visceral crises and shooting-pains, but neither head- 
nodding nor nystagmus. The lack of intelligence and the family his- 
tory are characteristic of Friedreich's disease. 

Prognosis and Treatment. — There is no cure for the affection. 
The treatment is designed to relieve the symptoms. 

ACUTE ENCEPHALITIS. 

Synonyms.. — Acute Polioencephalitis, superior or inferior (Wer- 
nicke), Acute Hemorrhagic Cortical Encephalitis. 

Etiology. — Encephalitis, or acute polioencephalitis, is an acute 
infectious disease, though the exact exciting cause is still unknown. 
It was first described by Striimpel, Leichtenstein, and Oppenheim. 
It may complicate or follow the exanthemata, influenza, pneumonia, 
erysipelas, diphtheria, septic endocarditis, or forms of otitis. I 
have seen two cases follow varicella. It may follow ptomaine poi- 
soning, or poisoning by alcohol, or wood alcohol, or carbonic dioxide. 
A traumatism of the head may be a predisposing factor. It is a dis- 
ease of infancy and childhood, but may occur in adults. 

Forms. — It may involve any part of the brain. Striimpel de- 
scribed it as a cortical lesion, Wernicke as an affection of the gray 
matter in the aqueduct of Sylvius, or the disease may affect the 
nuclear deposits in the medulla and according to distribution is called 
polioencephalitis, superior or inferior. In such cases there is an 
acute bulbar paralysis. In other cases the disease may affect a small 
area of the brain ; or the two hemispheres in both gray and white sub- 
stance ; or it may, as above, involve the medulla, the upper pari o\ 
the cord, and cerebellum. Thus the symptoms will differ according 
to the area of the brain and medulla affected. 

Morbid Anatomy. — The changes found in the brain-substance and 
cortex are similar to those described as occurring in the various 



860 DISEASES OF TEE XEBrOUS SYSTEU. 

forms of poliomyelitis. There is an acute hyperemia starting from 
the pia mater with distention of the bloodvessels and rupture and 
hemorrhages into the brain-tissue with infiltration of cells and leuco- 
cytes. There are various degrees of degeneration and destruction 
of nerve-tissue, neurones, axones, and dendrites. The changes are 
identical with those of poliomyelitis. After the acute stage has 
passed, absorption of cells and clots takes place and if the destruction 
of tissue has not been diffuse or in important foci, no trace is left 
behind. On the other hand, if important areas have been inflamed 
and destroyed, paralyses of varying extent are left, or if large cere- 
bral areas have been involved, imbecility or blindness may result. 
Among the foci there may be facial paralysis, varying ocular palsies, 
hemiplegia, and monoplegia. Cerebellar lesions lead to ataxia and 
in cord involvement symptoms referable to the cord remain. In one 
of my cases total blindness, which in the course of months improved, 
resulted; in another, a mild form of strabismus; in a third, a left 
facial and arm paralysis; and a fourth recovered without any pareses. 
The subsequent formation of connective tissue in the brain or cord 
may lead to epilepsy or multiple sclerosis of the cord. 

Symptoms. — There are two sets of symptoms : those of the onset 
and those due to the part of the brain affected. The history in most 
cases is similar. There may be a few days of indisposition, head- 
ache, and dizziness, followed by sudden vomiting, a chill or convul- 
sions, and then the patient passes into a condition of stupor or coma 
with a temperature which may be at first as high as 104° and then 
falls to the normal, or may be at times a degree or half a degree 
above the normal. In the stage of stupor or coma there is delirium, 
hyperesthesia, and restlessness, which may last with intervals of quiet 
for one or two or even three weeks. 

In all my cases it was fairly impossible at first to differentiate 
the symptoms from those of a meningitis. In one instance the diag- 
nosis of tuberculosis and in another that of cerebrospinal meningitis 
was made. I uniformly found neck-rigidity, taclie cerebrate, and 
Kernig's symptom with hyperesthesia. There was a mild degree of 
internal hydrocephalus as evinced by the ATaeewen sign and a subse- 
quent maudlin form of delirium. Once there was monoplegia of the 
left upper extremity, choked disc, and temporary blindness and stra- 
bismus. In another case there was optic atrophy and a complete 
blindness which improved in months. In a third case a period of 
maudlin delirium occurred followed by complete recovery without 
any pareses. In every instance I found that there was a leucocytosis 
of the polynuclear type, from 21,000 or 30,000 to 72,000 white cells 
to the cubic millimetre. 

Aphasia, temporary or permanent, may result or some form of 



ACUTE POLIOMYELITIS. 861 

word-blindness, hemianopsia, or permanent deafness, or blindness, as 
in one of my cases. Idiocy may result. Starr reports a case in 
which there were symptoms of cerebellar type, such as tremors of the 
hands and lower extremities. Again, with the symptoms referable 
to eyesight, there may be ocular palsies, ptosis, strabismus, or ophthal- 
moplegia. In another set of cases there are symptoms denoting 
bulbar paralysis, such as disturbances of speech, deglutition and 
respiration; in other words, glosso-labio laryngeal paralysis. Here 
the danger of a fatal issue is great. Lumbar puncture in my cases 
revealed a clear fluid with few flocculi, having a cytosis of 100 per 
cent, lymphocytes, containing sugar and albumin. 

Prognosis. — The prognosis as to life is good in most cases except 
such as show bulbar symptoms, which may by involving the respira- 
tory centres cause death. Epilepsy may follow later in life, espe- 
cially in children in whom the cortex of the brain has been severely 
involved. These cases include the so-called cortical epilepsy with 
sensory or motor aura (Starr). A mild form of mental deficiency 
or complete imbecility may sometimes result. 

Treatment. — In the acute stage, sedatives such as bromides and 
opium are indicated and cups to the nape of the neck and spine. Hot 
baths are comforting, especially where pain in the spine and extremi- 
ties is complained of. When the acute stage has passed, the general 
symptomatic treatment as in poliomyelitis is indicated. Patients 
should not be released from observation until it is certain that all 
danger from relapses, which, though rare, have occurred, is passed. 
In one of my cases blindness was discovered four weeks after the 
patient was thought to be apparently well. 

Lumbar Puncture. — Lumbar puncture is permissible in the acute 
stage of delirium and has a quieting effect on the patient. It has 
been recently proposed by Gushing to give all acute infectious cere- 
bral cases urotropin. This may be tried with a view to limiting the 
infective process through the cerebrospinal fluid which has been found 
to contain the drug a few minutes after its administration by the 
mouth. Where coma is complete and there are signs of respiratory 
or cardiac failure, lumbar puncture is attended with danger of sudden 
death. 

ACUTE POLIOMYELITIS. 

Synonyms. — Anterior poliomyelitis, epidemic poliomyelitis, acute 
atrophic paralysis, essential paralysis of children, infantile paralysis. 

Definition. — Poliomyelitis is an acute infectious disease, whoso 
main characteristic is a flaccid paralysis o( wide or limited extent, 
occurring within a few hours or days. Some o( the paralyzed mus- 
elos recover, others undergo atrophy. 



862 DISEASES OF THE NERVOUS SYSTEM. 

Occurrence. — This is the most common form of paralysis in chil- 
dren. It is questionable whether it occurs in foetal life. Duchenne 
reports the case of an infant twelve days old, hut such cases are apt 
to be examples of cerebral hemorrhage. It usually occurs in the 
first three years of life. Both sexes are equally affected. 

Etiology. — The etiology of this disease is still obscure. Though 
most observers concede its infectious nature, no specific organism 
has as yet been positively identified as causative. Geirsvold isolated 
a diplococcus from the throats and spinal fluid of patients suffering 
from the disease and Harbitz and Scheele found a similar organism 
in three cases. They could not reproduce the disease experimentally. 
As predisposing causes may be cited exposure to cold and disturb- 
ances of the gastro-enteric tract. Medin, Striimpel, and Zuppert 
found many cases occurred in connection with the infectious dis- 
eases, especially cerebrospinal meningitis, measles, and scarlet and 
typhoid fever. 

In the great New York epidemic, of the two thousand cases re- 
ported, fully 60 per cent, showed some disturbance of the intestinal 
functions, either preceding or accompanying the onset. The disease 
may occur sporadically or in epidemics. The most extensive epi- 
demics have been reported in Sweden and the United States. The 
epidemic in New York anel its environs in the summer of 1907 num- 
bered some two thousand cases. In the years following the New 
York epidemic there has been a marked prevalence of the disease, 
beginning in mid-summer and extending into the autumn months in 
the localities affected by the original outbreak. 

Morbid Anatomy. — Harbitz and Scheele have described the appear- 
ance in the brain and cord of cases occurring in the Swedish epidemics. 
' In the nervous system they found in the spinal cord a diffuse 
inflammation, chiefly in the gray matter and within this chiefly in 
the anterior horn. 

The inflammation could also be traced more or less in the white 
matter and in the pia mater, and especially in the medulla oblongata. 
Grossly speaking the inflammation extended along the whole length 
of the cord and was most extensive in the cervical and lumbar enlarge- 
ments. There was cellular infiltration of small and large mononu- 
clear lymphocytes, especially in the pia mater and white substance, 
with polymorphonuclear leucocytes ; in the cord substance there was 
cellular infiltration ; the ganglion cells were markedly degenerated ; 
over large areas of the cord, instead of the degenerated and disinte- 
grated ganglion cells, there were so-called neurophagons or leucocytes. 
In the cases which gave a clinical appearance of bulbar paralysis there 
was diffuse infiltration all along the cord, often of a hemorrhagic 
character. Small hemorrhagic cavities were found especially in the 



ACUTE POLIOMYELITIS. 863 

anterior horn, with extensive destruction of nerve-tissue elements. 
The pia mater was distinctly inflamed and the inflammation seemed 
to extend from the pia into the substance of the cord. 

The inflammation reaches its highest intensity in the anterior 
horns because they are supplied from numerous large bloodvessel-. 
The infiltration of the pia extended to the medulla and pons and cere- 
bellum, especially in the mesial line along the base of the brain, and 
to the vessels at the base and the Sylvian fissure. The infiltration of 
the pia could be traced over the surface of the brain and in the sulci, 
central foramen and median fissures. 

The Brain,- — There was more or less encephalitic inflammation 
about the medulla and pons, especially about the fourth ventricle and 
in the substantia reticularis and in most of the nuclei of the cranial 
nerves. The inflammation was particularly marked around the 
blood-vessels from the anterior surface through the raphe ; the lower 
part of the pons and medulla were much less involved, as also the 
pyramids, olives, crura and the anterior surface of the pons. 

The inflammation also was of a hemorrhagic character, but not 
so intense as that found in the cord, with considerable oedema at the 
bottom of the fourth ventricle. In the cases where the symptoms 
were due, it was believed, to acute bulbar paralysis, the basal ganglion 
were involved in inflammation. 

The largest infiltrations were found in the lower part of the optic 
thalamus. The white substance of the external and internal capsules 
* were generally involved to a more or less extent. 

Certain parts of the pia were involved and the inflammation 
seemed to extend from the pia into the brain substance. There were 
small perivascular infiltrations. There were also numerous large 
infiltrations in the cortex of the central gyri with slight degeneration 
of the ganglion cells. The frontal gyri were involved, especially the 
posterior, and on the median surface much more than the outer lobe 
and gyri. 

In a severe and fatal case of acute poliomyelitis there was dif- 
fused inflammation of the entire cord, pia mater, medulla and pons, 
of the basal ganglia and often of the cortex of the brain to a greater 
or less extent. In those with limited paralyses the same changes 
could be demonstrated to a less degree in the cord, the basal ganglia 
and medulla and in a few cases in the cortex of the brain, thus proving 
that poliomyelitis is rather a general process even in the milder ease-. 

It has been thought in various epidemics that in such ascending 
paralyses as Landry's paralysis, followed by bulbar symptoms and 
death, that the inflammatory process extended from the cord to the 
medulla. This is erroneous, as such apparent communications do 
not exist. The cord and medulla are infected from the meninges 



864 DISEASES OF THE NERVOUS SYSTEM. 

along the bloodvessels. A large percentage of cases of Landry's 
paralysis have been shown to be of the nature of a severe poliomy- 
elitis, with extension to the medulla. 

In four cases of bulbar paralysis which these authors examined 
and which were fatal, the bulbar symptoms being severe dyspnoea, 
cyanosis, difficulty in micturition, deglutition, articulation, and paral- 
ysis of the soft palate and of the ocular muscles, there was severe and 
intense inflammation of medulla oblongata, with considerable destruc- 
tion of cord, giving the same appearance as that of any beginning 
poliomyelitis of a hemorrhagic nature. At the same time there was 
similar inflammation in the cord often less intense. 

Anatomically these cases do not differ from ordinary cases of 
acute poliomyelitis, the difference being only in distribution and 
degree of the intensity of the inflammatory process. 

Symptoms. — The general symptoms divide themselves into four 
distinct periods : those of the onset ; the paralysis ; the period of retro- 
gression, in which some of the paralyzed parts recover, others remain- 
ing paralyzed; and finally the period of permanent paralysis and 
atrophy of muscle. 

Onset. — The onset is acute but there may be indefinite symptoms 
for some days preceding. The onset may be followed by remission 
of symptoms and then new symptoms may appear after a few days. 
Fever is among the first symptoms with or without convulsions or 
vomiting. These are followed by sopor, which may deepen into coma. 
Headache, mostly of an occipital character, may accompany the 
fever. Cerebral symptoms may be present, consisting of pain in the 
nape of the neck, sensitiveness over the spinous processes, sometimes 
accompanied by hypersesthesia or retraction of the head or orthotonos 
lasting over a week. The pains are of short duration and may sub- 
side with the fever or they may persist for a week or more. The 
pains sometimes radiate into the extremities, but are unaccompanied 
by joint involvement. There are frequently sensitiveness of nerve 
and muscle. Tremors may be an early symptom, as well as ataxia, 
the latter being uncommon. 

Gastro-enteric disturbances, such as severe vomiting and diarrhoea 
with fetid discharges, are quite common, and at other times there is 
a history of inordinate constipation. 

During the initial period incontinence of urine for three or four 
days has been observed. 

Forms of the Disease at the Onset. — The disease may be 
clinically divided into distinct forms according to the predominance 
of one or the other set of symptoms of the onset. 

1. The poliomyelitic or spinal form. 



ACUTE POLIOMYELITIS. 865 

2. The form simulating an acute ascending or descending paral- 
ysis (Landry's paralysis). 

3. The bulbar or pontine form. 

4. The encephalitic or cerebral form. 

5. The polyneuritic form. 

6. Abortive forms. 

Some also mention the ataxic form, but this is rare. 

1. Poliomyelitic Form. — The poliomyelitic form is that which 
has always been known as anterior poliomyelitis and was so described 
by Charcot. This is a paralysis flaccid in character appearing after 
an initial fever and vomiting and which is purely a motor paralysis. 
Two or three days after the onset there is a paralysis which at first 
may be incomplete. In some cases the paralysis goes no further and 
may even improve, in others there is a progressive involvement of one 
or more extremities. For the most part only certain groups of mus- 
cles are affected, such as the peroneal group ; the quadriceps femoris ; 
and the shoulder group, including the deltoid, the extensors or 
flexors. The paralysis may be partial or complete, and may amount 
to monoplegia or paraplegia, and in the acute stage it may be more 
decided than later on. 

2. Form Simulating Landry's Paralysis.- — The second form is 
that which simulates an ascending or descending progressive paral- 
ysis, such as has been known under the title of Landry's paralysis. 
This form of poliomyelitis numbers among its cases many which are 
fatal. Wickman found among 159 fatal cases 36 of this form. In 
children it is recognized with great difficulty because in the initial 
period, the patients being confined to their bed, the beginning paral- 
ysis is not noticed. Thus many cases of this form are generally not 
diagnosed in children. In adults a more complete history is obtain- 
able and more cases of this form are therefore observed at this time 
of life. 

3. Bulbar or Pontine Form. — In this form the nuclear involve- 
ment in the medulla takes a leading role in the symptomatology fol- 
lowing the immediate onset. The initial symptoms begin with fever, 
chills, and pains in the head, neck and back. There is vomiting, 
neck-rigidity and spinal tenderness. The movements of the extremi- 
ties are painful and there is sensitiveness of the nerve-trunks. The 
nuclear palsies which are so characteristic of this form may be accom- 
panied by a paresis or paralysis of one or other extremity or of the 
muscles of the abdomen or back. The patients cannot sit up or hold 
the head up. 

There are ocular palsies and the face may be involved. The 
intercostal muscles may be paralyzed and also those of the abdomen. 
The breathing is then purely diaphragmatic with protrusion of the 

55 



S66 



DISEASES OF THE NEEYOES SYSTEM. 



Fig. 198. 



abdomen with each descent of the diaphragm and marked by labored 
ahe nasi. The ocular palsies vary from an abdncens paralysis to 
complete ophthalmoplegia. Hypoglossal paralysis, or paralysis of 
the soft palate, may be present. If there is glosso-labio-laryngeal 
paralysis, there is difficulty in swallowing. Only half of the tongue 
may be protruded or the paralysis may involve the respiratory nuclei. 
If the oculomotor and abducens nucleus are affected ophthalmoplegia 
results. Medin records such a case and I have seen one in the New 
York epidemic. If the celiospinal centre is involved there is the 
Oppenheim symptom of a narrowing of the ocular fissure and pupil 
of the eye on the paralyzed side. Optic atrophy or amaurosis may 
occur. 

If the ninth, tenth and eleventh nerves are affected deglutition is 
disturbed with the pharyngeal paralysis. Cheyne-Stokes respiration 

may be seen as a result of an affection of 
the respiratory centre and involvement 
of the accessorius. 

The clinical history of this form of 
poliomyelitis very closely resembles the 
condition described as polioencephalitis. 
The patient is taken with vomiting and 
fever. The latter continues, though the 
vomiting may cease or become incessant. 
After a day or two of fever it is noticed 
that there is a weakness in the extremi- 
ties and the patient takes to bed. Sopor 
now sets in and increases, or it may alter- 
nate with restlessness or delirium. It is 
now noticed that the patient swallows 
with difficulty and may have spasms of 
choking if any fluid is swallowed. There 
is shallow respiration. The fever after 
a few days subsides to the normal and an 
examination shows the patient to be soporose, though roused on inter- 
ference. There is irritability. Xuclear palsies, such as facial palsy 
or strabismus, and abdominal breathing, may be marked on account 
of the paralysis of the muscles of respiration (Fig. 198). Rales 
and rhonchi appear in the chest. There is mild hydrocephalus in 
many cases. The patient may recover in this stage or go on to more 
complete bulbar paralysis and death. There may in this form be no 
paralysis of the extremities, though a weakness is present. The 
knee jerks are increased. There may be slight monoplegia of either 
upper extremity. 




Poliomyelitis involving only 
the facial nerve. Encephalitic 
and bulbar type. 



ACUTE POLIOMYELITIS. 867 

4. Encephalitic or Cerebral Form. — The encephalitic or cerebral 
form is that in which the onset is characterized by meningeal symp- 
toms. There are pain, headache, neck-rigidity, and even uncon- 
sciousness. In some cases these symptoms soon subside on the ap- 
pearance of the paralysis, in others they persist and take a leading 
role, so that at first it is almost impossible to decide whether there is 
a true meningitis or not. Some days must elapse before such a dif- 
ferential diagnosis is possible and in many cases a lumbar puncture 
must be performed to decide the question. 

5. Polyneuritic Form. — The polyneuritic form has caused much 
discussion as to whether there can be true neuritis in such cases. 
The truth is that in some cases it is almost impossible to differentiate 
and to decide as to the presence of a neuritis. The pains which have 
been mentioned are prominent symptoms combined with extreme sen- 
sitiveness of nerve and muscle. In neuritis there is motor paralysis 
with complete recovery of muscle ; the opposite is true of poliomyelitis. 

6. Abortive Form. — Finally, in all epidemics of poliomyelitis, 
alongside of the true cases which have developed all the symptoms 
of paralysis, there are the abortive cases, in which there occur all the 
symptoms of the onset of the disease, but in which there is no paral- 
ysis, the patients being ill but a few days and making a complete 
recovery. In other words, there is some general infection, but no 
lasting symptoms. 

To illustrate: a child during an epidemic of poliomyelitis, after 
an indefinite period of either constipation or some disturbances of 
the functions of the intestine, is taken with fever. This fever lasts 
a few days ; at first it is high and then subsides. There is restless- 
ness, crying out at night, delirium, and complaint of pain in the back 
of the neck and head in young children. There is some rigidity; 
there is also a slight increase of fluid in the ventricles of the brain, 
as is evinced by percussion. There are no paralyses or pareses; at 
most the reflexes at the knees are increased. There is in infants and 
young children a distinct loss of weight. These symptoms may be 
attended by inordinate and uncontrolled vomiting, lasting over days. 
The patients recover, the disease leaving no trace behind except gen- 
eral weakness. There is thus a close resemblance between these 
cases and an encephalitis of favorable issue. 

1. Ataxic Form. — In the so-called ataxic form, after the onset. 
it is noticed that the children have an uncertain gait and walk with 
limbs spread apart, very much as in Friedreich's ataxia. In some 
cases the patellar reflexes are increased, in others there is no atrophy 
of muscle. In most cases the ataxia amounts to a paresis with 
ataxia, but there is no isolated pure ataxia. 



868 



DISEASES OF THE NERVOUS SYSTEM. 



Paralysis. — The paralysis is a flaccid paralysis, a loss of power 
which is complete in two or three limbs or in parts of extremities. 
Seeligmhller found the right lower extremity, the left lower ex- 
tremity, the right upper extremity, and the left upper extremity, 
involved in the order named. Medin found that in a group of 65 
cases the incidence of paralysis was as follows : both arms, 20 cases ; 
right lower extremity, 6 cases; right upper extremity, 2 cases; right 
arm, 2 cases ; left arm, 2 cases ; arm and leg, 1 case ; leg and neck 
muscles, 1 case; arm, leg and abdominal muscles, 1 case; chest inter- 

Fig. 199. 




Acute atrophic paralysis involving the left upper and lower extremities'. 



costals, 2 cases; arm, lower extremity and buttocks, 2 cases; neck 
muscles, 2 cases ; muscles of the whole body, 1 case ; paralysis of the 
lumbar spine and abducens nerve, 1 case; paralysis of the lumbar 
spine and oculomotor nerve, 1 case; complete spinal paralysis and 
facial paralysis, 1 case; complete spinal paralysis, facial and occip- 
ital, 1 case ; complete lumbar paralysis, 1 case ; and paralysis of facial 
nerves and polyneuritis, 1 case. 

The remainder of his cases consisted of forms of polyneuritis, 
facial and monoplegias, and paralysis of the cranial nerves with polio- 
encephalitis. 

After the first onset of the paralysis, some of the muscles may 



ACUTE POLIOMYELITIS. 



869 



recover. Thus a child who has been unable to sit up or move the 
arms will recover the power to do so. In such cases one leg only 
may remain permanently paralyzed. 

Paralysis may develop slowly in the course of one or two weeks. 
After that time it comes to a standstill. In a period of from one to 
three months either recovery will take place or the paralysis will be 
complete with accompanying atrophy. 

In some forms of poliomyelitis, especially those combined with 
symptoms of bulbar nuclear involvement, the patient, though the 

Fig. 200. 




roliomyelitis showing atrophy of left upper and lower extremity and trunk muscles. 

paralysis at first may have involved both upper and lower extremities, 
the muscles of the neck, back, thorax, and even abdomen, may recover 
in a few weeks or months to the extent of being able to walk about 
and use the upper extremities, but the muscles of the back on either 
side may remain permanently involved, so as to give rise to unsightly 
spinal curvatures. In other eases which at iirst showed a general 
widely distributed paralysis, there may renin in only a paralysis with 
atrophy o( groups oi' muscles in both upper extremities. Thus the 
eventual permanent paralysis may in no way be indicated by the 
paralysis apparent in the early period ol the disease. 



870 



DISEASES OF THE NERVOUS SYSTEM. 



Atrophy. — Atrophy in the paralyzed muscle is very character- 
istic of the disease. It may be seen as early as the first week. Ac- 
companying it, and appearing from the fifth to the seventh day, is 
the reaction of degeneration in the paralyzed muscle and nerve. The 
faradic and galvanic irritability of nerve and muscle are increased 
for the first two days. They then rapidly diminish, the former dis- 
appearing completely. The galvanic irritability remains increased 
for from two to six months ; it then diminishes, and if the paralysis is 
permanent, disappears at the end of one or two years (Fig. 201). In 



Fig. 201. 




Poliomyelitis. Left facial paralysis, left upper and right lower extremity involved 

with atrophy. 



rare cases all electrical irritability disappears from the onset. In 
others the faradic irritability in certain fibres and muscles returns 
after from six to twelve months. These muscles may partially recover, 
but remain atrophied and weak. There is usually no loss of sensa- 
tion, but if it does occur, there is incontinence of urine. Reflex at 
the patellar tendon is lost and myotonic irritability is either lost or 
diminished. In cervical disease of the cord, or when only the pos- 
terior tibial muscle, or the muscles of the feet are paralyzed, the 
tendon reflex at the knee is present or increased. In rare cases, the 
inflammation may spread from the anterior horns to the lateral 
columns. The lower extremities may then be paralyzed but not 
atrophied, and clonus may be present. 

Growth of bone is retarded, and one foot may after a time become 
shorter than the other. The joints become the seat of subluxations 
through the laxity of the muscle and lack of support. The articular 
ends of the bones are not held in apposition. Through the shorten- 



ACUTE POLIOMYELITIS. 871 

ing of some muscles and the traction of others there will result various 
forms of talipes. The muscles in front of the tibia are affected more 
than those of the calf. The extensors of the thigh are more fre- 
quently paralyzed than the flexors. 

The muscles of the whole arm may he paralyzed, or, as in Erb's 
paralysis, only those of the deltoid group. The serratus, the pecto- 
ralis, the muscles of the back and neck, and the diaphragm may all 
be affected. 

Diagnosis. — The diagnosis may offer difficulties in those cases 
which simulate meningitis and neuritis. The onset of the disease 
may mislead into the suspicion of an infectious disease; indeed, at 
first this would seem the most natural assumption. The progress of 
the disease and the appearance of the paralysis will clear up the diag- 
nosis. The complete recovery in neuritis, the pain of neuritis, and 
the pain at the nerve exits, will all aid in the diagnosis. 

The appearance of a flaccid paralysis will clear up the case. 
Some of the meningeal forms are not so easily differentiated from 
forms of true meningitis ; in fact, I have been forced in some elusive 
cases to make a lumbar puncture to clear up the diagnosis, even in 
the face of a paresis of the extremities, for this may be present in 
meningitis. The leiicocytosis, which is also present in forms of polio- 
myelitis, does not aid any in the diagnosis, as it is similar to that of 
cases of meningitis. 

The differential diagnosis of poliomyelitis from cerebral palsy is 
also not so easy at times. The paralysis in cerebral palsy is not a 
flaccid paralysis as in poliomyelitis. The reflexes are increased or 
normal in some cases of poliomyelitis and therefore, though absent 
in most cases, this absence may aid us in differentiating from cases 
of cerebral palsy. In the latter disease the absence of atrophy of 
muscle and the presence of post-hemiplegic chorea will aid in the 
differential diagnosis. The diagnosis of monoplegia and facial pal- 
sies not poliomyelitic in origin must be made from the history of 
the case. 

Prognosis. — The prognosis varies in the mild forms of the disease, 
such as the purely spinal form, and the epidemic types, such as the 
bulbar and pontine and Landry type. The mortality, therefore, 
ranges from 6 to 13 per cent., the latter being the mortality in the 
Swedish epidemic recorded by Wickman. A great many cases make 
a complete recovery without any residual paralysis. In these cases 
are included the abortive types described by Wickman. Most of the 
deaths occur in epidemics from the fourth to the tenth day, so that 
if the case has lasted ten days, the outlook as to life is good. Many 
cases with a complete paralysis of all four extremities recover with 



872 DISEASES OF THE NERVOUS SYSTEM. 

an isolated paralysis, or a paraplegia may leave a monoplegia or only 
paralysis of a certain group of muscles. A positive view should not 
be expressed as to ultimate recovery until six months have elapsed 
since the onset of the disease. In other words, the physician should 
not be too ready to assume the hopeless outlook, but rather encourage 
the parents of the child as to ultimate recovery of a paralysis. 

Sequelae. — A cord which has once been the seat of this disease is 
naturally susceptible. Gowers states that he has seen chronic disease 
of the cord supervene later in life. Progressive muscular atrophy or 
lateral sclerosis may at some later time appear in the cord. 

Treatment. — In the stage of onset the treatment is symptomatic. 
If delirium and pain exist the coal-tar drugs, such as phenacetin or 
aspirin, may be used in full doses. In severe cerebral symptoms 
lumbar puncture is indicated and not only excludes meningitis but 
relieves the meningism. When the paralysis appears and pains still 
continue warm baths offer great relief. Sleep is obtained by means 
of chloral hydrate, bromides, or opium. The bowels at first should 
be well evacuated with calomel and during the illness enemata are 
useful. The diet should be light and assimilable. After the first 
week, if the constitutional symptoms have subsided and the paralyses 
have appeared, strychnine in full doses is indicated. With the in- 
ternal administration of the drug is combined a daily injection of the 
sulphate of strychnine into the substance of the paralyzed muscles. 
Daily massage of the affected muscles and mild faradic current 
applied for five minutes daily will keep up the tonicity of the para- 
lyzed muscle-groups. In the early stages dry-cups applied to the 
nape of the neck and along the spine will, according to some, be of 
utility. In the stage of muscular contracture it is well to begin 
early the application of splints and orthopedic braces to prevent 
deforming contractures. Tenotomy is only called for in extreme 
contracture of tendon. 

THE JUVENILE FORM OF PROGRESSIVE MUSCULAR ATROPHY 

(ERB'S TYPE). 

This disease is characterized by a weakness and progressive wast- 
ing of certain muscles. It begins in childhood or early youth, and 
involves, as a rule, the shoulder-girdle, the upper arm and pelvic 
girdle, and the thigh and back. The muscles of the forearm and leg 
remain for a time intact. This atrophy may be associated with true 
hypertrophy or pseudohypertrophy of some muscle. The pectoralis, 
the trapezii, the latissimi dorsi, the serrati. the rhomboids, the upper 
arm muscles and supraspinators, are apt to be wasted. The deltoid?. 



PLATE XXXVII 




Erb's Paralysis in a Child Twenty-six Months of Age. 
Atrophy of the deltoid, subluxation of the arm; bony 

prominences marked. 



PSEUDOHYPERTROPHIC MUSCULAR PARALYSIS. Hit 

supraspinal, and infraspinati may bo normal or hypertrophied for a 
time. There are no fibrillar contractions, no disturbances of sensa- 
tion, and no reactions of degeneration and visceral disturbances. 

THE LANDOUZY OR DEJERINE TYPE OF THE FACIO-SCAPULO- 
HUMERAL FORM OF MUSCULAR ATROPHY. 

This form in no way differs clinically or pathologically from the 
juvenile form of muscular atrophy. Authors include in this class 
all cases in which the atrophy begins in early life, as a rule, in the 
muscles of the face. The patients have a peculiar expression — so- 
called a facies myopathique." The lips are thickened ("bouche de 
tapir " or tapir mouth) . The shoulders later become atrophied. The 
supraspinal, infraspinati, and the flexors of the hands and fingers 
remain normal, as do the muscles of deglutition, mastication, respira- 
tion, and the laryngeal and ocular muscles. There are no fibrillary 
twitchings. The spinal forms of progressive muscular atrophy differ 
from primary dystrophy in that the onset of the latter affection is in 
the upper extremities. The disease is not hereditary, and fibrillary 
twitchings and electrical reactions of degeneration are absent. 

Both these forms are probably clinical varieties of the pseudo- 
hypertrophic form of paralysis. 

PSEUDOHYPERTROPHIC MUSCULAR PARALYSIS. 

This disease is characterized by a progressive change in the size 
of many of the muscles of the body and by a diminution of their 
power. It was described by Duchenne in 1861. Since then the most 
notable work on the subject has been done by Gowers, of England. 
and Sachs, of this country. The male sex is more frequently affected 
than the female. From two to eight members of the same family are 
often affected. Isolated cases are uncommon. The disease frequently 
affects the members of one sex in a family group. It is congenital 
but not hereditary. The antecedent cases, if there are such, can 
usually be traced on the mother's side of the family. The mother 
may be herself unaffected. Intemperance does not seem to exert any 
influence on the occurrence. 

Gowers notes that frequent marriage of parties closely related 
tends to predispose to the development of the disease in the children. 
In one-third of the cases the disease appears when the child begins to 
walk, and in children who are late in learning. It may manifest 
itself in the mid-period of childhood. In another third of the eases 
the children are in apparently good health until the fourth or sixth 
year. Three-fourths of the cases show symptoms of the disease 
before the tenth year. The disease may not manifest itself until 



874 DISEASES OF THE NERVOUS SYSTEM. 

after puberty, and may only be noticed during convalescence from 
some intercurrent acute disease. 

Symptoms. — The symptoms are impairment of power and change 
in the form of groups of muscles or of single muscles. The impair- 
ment of power is at first not very apparent. The muscles of the 
calves enlarge, and show a very characteristic and significant hyper- 
trophy. Mothers are at first pleased with what appears to be mus- 
cular development of the children (Gowers). It is then noticed that 
although the muscles of the calves and glutei are large, the children 
are easily fatigued in mounting stairs. They fall easily and rise 
with difficulty. This loss of power is at first interpreted as weak- 
ness, but when it is found to be progressive the children are brought 
to the physician. 

The gait becomes pronouncedly oscillating. The body is inclined 
so that the centre of gravity is brought successively over each foot. 
In trying to rise from the ground the patient places a hand on each 
knee in a very characteristic fashion. By grasping the thighs and 
throwing back the weight of the trunk, the patient helps himself into 
the erect posture. The weakness of the muscles finally becomes ex- 
treme. The patients can neither stand, walk, nor sit upright. They 
become bedridden. In the early stage, the muscles of the trunk may 
be normal, small, or atrophied, and those of the lower extremities 
much enlarged. Single muscles or groups of muscles of the arm and 
forearm may be enlarged (Plate XXXIX.). Finally, as the atrophy 
and weakness increase, there are contractures and distortions of the 
extremities and trunk. Equinus, lordosis, and lateral curvature are 
very marked. The knee may become fixed and distorted by contrac- 
tures. The muscles most frequently affected in the beginning are 
those of the calves of the legs. These sometimes attain an enormous 
size. Those of the anterior part of the leg are not so much enlarged. 
The flexors of the knee commonly escape. The glutei and lumbar 
muscles are enlarged. 

The infraspinatus muscle is frequently enlarged, and stands out 
prominently; it is often mistaken for the lower edge of the scapula. 
The deltoid is often large ; the serratus and the pectoralis are rarely 
affected. The triceps and biceps are frequently large, but often only 
in parts. The muscles of the forearm suffer only in a minority of 
cases. The intrinsic muscles of the hand are never affected. In 
that respect the disease is sharply distinguished from atrophies of 
spinal origin. The muscles of the neck are, with the exception of 
the clavicular portion of the sternomastoid, rarely affected. All the 
muscles affected are weakened, the smaller and atrophied muscles 
more so than the others. There is reason to believe that many mus- 
cles not visible are much affected. 



PLATE XXXIX 




Pseudohypertrophic Paralysis in a Boy Eight Years of Age. 
Hypertrophy of the infraspinati well shown; also atrophy of 
the muscles of the thorax and hypertrophy of the glutei and 
the muscles of the lower extremity. 



PSEUDOHYPERTROPHIC MUSCULAR PARALYSIS. HI?) 

Electrical Reaction, — This is altered when weakness sets in. 
The electrical contractility to galvanic and faradic stimulus finally 
disappears. 

Reflexes. — The knee-jerk is at first normal. It later diminishes 
and finally disappears. It is never increased in a pure case. In one 
case in my hospital service there were increased reflex at the knee 
and foot-clonus. This case gave a history of a blow across the hack. 
Sachs, with whom I saw the case, suspected a complicating myelitis 
of the cord. 

Sensation, — Sensation is unaffected and the sphincters remain 
normal. 

Course. — The course of the affection is prolonged and tedious. 
The disease is progressive. It may be ten or fourteen years before 
the patients succumb. They die of some intercurrent disease. If 
the disease appears after puberty, the course is slower than in cases 
in which the first symptoms are noted in early childhood. 

Varieties. — There are cases in which only one muscle or group 
of muscles of the extremities is enlarged, the others being small or 
normal in size. There are other cases in which all the muscles are 
small and waste progressively. 

Complications. — Chorea, poliomyelitis, myelitis, mental deficien- 
cies, and epilepsy may complicate the affection. 

Morbid Anatomy. — The gray matter of the cord and the nerves 
are normal in appearance. There may be slight hemorrhages. The 
neuroglia-cells have sometimes been found to be increased. The 
disease is, however, primarily one of the muscle-tissue. The muscles 
are pale-yellow. They are replaced mainly by fat and connective 
tissue. The muscle-fibre is narrower than is normal, although in 
advanced cases the residual muscle-fibre may retain its transverse 
striation. Where the muscle-fibre is narrow it becomes granular or 
is the seat of fatty or waxy degeneration and vacuolization. Empty 
sarcolemma-sheaths are seen. 

Diagnosis. — The diagnosis is made from the progressive weak- 
ness, the gait, and the mode of rising from the recumbent position. 
The peculiar enlargement of the muscles of the calf and infraspi- 
natus, the atrophy of the latissimus dorsi and lower part of the 
pectoralis, and the immunity of the intrinsic muscles of the hand 
are characteristic. In the stage of contracture, this disease differs 
from congenital spastic paraplegia in that there is no increase of 
deep reflexes. 

Prognosis.- -The prognosis in children is grave. The affection is 
progressive. 

Treatment.— Much can be done for the patients by means of mas- 
sage and electricity. In the stage of contractures, while there is still 
power, relief can be secured by tenotomy. 



876 DISEASES OF THE XEEVOUS SYSTEM. 

IDIOCY. 

Idiocy is not of itself descriptive of any one disease or condition. 
It is a generic term and the subject of idiocy is considered here for 
the sake of completeness and also to impress upon the physician cer- 
tain points which will be of value to him in his daily work. Ireland 
defines " idiocy as a mental deficiency or extreme stupidity, the result 
of some disease or malnutrition of the nervous centers. It occurs 
before birth or before the evolution of the mental faculties in child- 
hood." From this definition it will be seen that there are forms of 
idiocy which are not included here, such as the juvenile forms of 
amaurotic idiocy, which may supervene even after the formation of 
the mental faculties. In America we have the terms mental defects 
or mental backwardness or feeble-mindedness, which are sometimes 
used in a humane and considerate way to cover certain forms of mild 
idiocy or imbecility, for there is to some a sense of offense in the term 
idiocy; why it is hard to say. If we say to a parent that a child is 
feeble-minded, it does not seem to strike as harshly on the sensibilities 
as when the crude term idiocy is used. 

Frequency. — Idiocy is quite a frequent condition in America, 
though it is a very difficult matter to decide as to the comparative 
frequency because in all countries parents and even physicians are 
loath to characterize children in this way and thus in a general census, 
on account of this partial concealment, only inaccurate data can be 
obtained. According to Fernald (1884) one in every 500 individ- 
uals in the United States is feeble-minded; in England and Wales, 
one in 771 ; in France, one in 1028; and in Prussia, one in 730. 
This is quoted only for the purpose of showing how frequent the con- 
dition really is and that it can be scarcely ignored. 

Etiology. — The etiology of idiocy is certainly varied and differs 
very much as to the form under consideration. Thus there are some 
forms which are acquired after birth, such as those Avhich follow an 
encephalitis, infectious diseases, or a meningitis. Their etiology is 
well-defined and is that of the original disease. On the other hand 
there are forms of idiocy, such as the Mongolian or the amaurotic, the 
causation of which is still obscure. The predisposing causes also are 
rather uncertain. It is found that 20 to 50 per cent, of idiocy occurs 
in families of neurotic tendencies and in consanguineous marriages. 
This does not dispose of the subject, for it does not tell the direction 
in which these neurotic tendencies eventually tend to the production 
of idiocy. Intemperance in the use of alcohol in the parents is said 
to tend to the increase of the prevalence of idiocy ; a contention which 
is not susceptible of direct proof. Care and worry on the part of the 
mother during pregnancy undoubtedly may be so severe as to react 
against the foetus. I have seen a number of examples of genetons 



IDIOCY. 877 

idiocy in which, there was a distinct history of fright or morbid de- 
pression on the part of the mother during pregnancy. 

Classification. — As our clinical and experimental knowledge ad- 
vances the classification of the various forms of idiocy must neces- 
sarily change. 

1. Genetous Idiocy. — This term was introduced by Ireland to 
include all those cases which are congenital, that is, born with idiocy 
and in whom the cause is obscure. Such would be the Mongolian 
idiocy or amaurotic idiocy, both fully treated of elsewhere. 

2. Microcephalic Form. — This form of idiocy is just as much of 
obscure origin and might be classed as a form of congenital idiocy 
with lack of cerebral and cranial development. Some of these cases 
at the age of eleven and twelve years have been found to have a head 
circumference of 14-J inches and 13J inches respectively. Some of 
my own cases have shown not only a small head circumference for 
the age, but other marks of degeneration. 

There are various degrees of microcephalus, from the extremely 
small head to the head which almost equals the normal in its circum- 
ference. Other dimensions of the head in these microcephalic idiots 
are also smaller than normal, thus tending to contract as a whole the 
cranial cavity. Taking six of my own cases, the following measure- 
ments were obtained at 5 and 6 months : a head circumference in two 
patients of 37^ centimetres and 33 centimetres respectively; a third 
case of extreme microcephalus measured 13| : centimetres in circum- 
ference. An infant 13 months old had a cranial circumference of 
32^ cm.; another of 2 years, 44 centimetres; and a sixth case of 2 
years, 43 centimetres. In the case of extreme microcephalus the 
anterior fontanelle was closed; in the less marked forms of micro- 
cephalus the fontanelle may be found widely open. It is thus not 
true that the closure of the anterior fontanelle determines the size of 
the brain or skull in these cases. 

With all forms of microcephalus there are other evidences of irre- 
parable change in the cerebral substance, such as spasticity or paral- 
ysis of the extremities or convulsions later on in childhood, or blind- 
ness and deafness, and total lack of intelligence except of the most 
animal type and that of the lowest form of animal life. The growth 
of the skull is very slow; thus in one case at the age of 2 months the 
skull measured 34-| cm., and at the age of 12 months 39^ em. hi 
another case in which lambdectomy had been performed the skull 
had grown only 5 cm. in a year and a half. The shape oi the head 
in all microcephalics is pyramidal in form, the forehead very low and 
narrow. 

The operation of lambdectomy first advocated by Lannelongue 
has not proved oi' any avail in theso eases, as the whole operation was 



878 DISEASES OF THE NEEFOUS SYSTEM. 

founded on the theory that the smallness of the head, and therefore 
the brain, was due to a premature closure of the anterior fontanelle 
and the sagittal suture. I have repeatedly demonstrated that in some 
typical microcephalics the fontanelle was widely open, so that the 
smallness of the skull can be hardly traceable to the above once widely 
accepted theory of premature closure of suture or fontanelle. 

3. Hydrocephalic Form. — The hydrocephalic form of idiocy may 
be congenital or acquired. Both forms are fully discussed elsewhere, 
both under the heading of congenital hydrocephalus and meningitis, 
where the acquired form of hydrocephalus is fully described. 

4. Epileptic and Paralytic Forms. — The epileptic and paralytic 
forms of idiocy are fully considered in the chapter devoted to the 
various forms of cerebral palsy, as are also those forms of idiocy which 
are the result of an inflammatory condition. The latter are treated 
of in the chapter on Encephalitis. 

5. Cretinic Form. — The cretinic form of idiocy is one of the 
forms whose etiology has been greatly cleared by experimental path- 
ology and its characteristics are considered elsewhere. 

6. Sclerotic and Syphilitic Forms. — The sclerotic and the syph- 
ilitic forms of idiocy are not as clearly denned as some of the other 
forms. 

Symptoms. — We can scarcely speak of the symptoms of idiocy, a 
mental state which is in itself a symptom of a condition of the ner- 
vous system. All idiotic children, however, have certain well-defined 
characteristics. Anatomically the facies in most all the forms are 
easily recognizable. The Mongolian idiot, the cretinic idiot, the 
microcephalic idiot, show in a glance facies which, when once seen, 
are not easily. forgotten. This is not so of some of the milder forms 
of mental backwardness which follow either intra-uterine or post- 
natal encephalitis. In such cases the children may have an almost 
normal appearance. It is only after close study that some mental 
defect is discovered. The physician must therefore defer judgment 
in all doubtful cases. 

This is especially to be emphasized, as some of these children can- 
not be called idiots in the full sense, but are rather mental defectives 
of a high grade. Some of these forms of idiocy are useful members 
of society. I have seen a blind, genetous, microcephalic idiot who 
was a most excellent interpreter of Wagnerian music and whose con- 
versational powers were undoubted, but who nevertheless was a mental 
defective. Some idiots have a violent temper; others are mild and 
docile. Some can be taught to be self-supporting; others must be 
cared for. The high palatal vault has been brought forward as a 
characteristic trait, but it is only one of the anatomical peculiarities 
of idiots which is occasionally seen in normal individuals. Deformi- 



DEFORMITIES OF SKULL AND SPINAL CANAL. 



879 



ties of the extremities, blindness, deafness, rumination, and slovering 
all occur in the various forms of idiocy. As a direct result of mal- 
nutrition fully two-thirds of all idiots are tuberculous or scrofulous. 

Treatment or Management. — The management of mental defectives 
of all grades is, strange to say, a study of recent times. In large 
cities, such as New York, the care of the higher grade of mental 
defectives is but just receiving the public attention it deserves. It 
is all a matter of careful classification and education. In forms of 
idiocy or mental obscurity in which therapy is of avail, as in cretin- 
ism, the subject has received attention elsewhere. 

The operative treatment of microcephalic and hydrocephalic forms 
of idiocy has been fully noticed. The marked encephalitic forms 
are past remedy and the epileptic or eclamptic and Mongoloid forms 
must be cared for in separate asylums or institutions, where special 
methods and attendants are at hand. 

DEFORMITIES OF THE SKULL AND SPINAL CANAL. 

These deformities do not strictly belong to the disease of infancy 
and childhood. Only the forms most commonly met are here con- 
sidered. 

Fig. 202. 




CramoscJiisis. Deficiency of the frontal, parietal, and most of the occipital bones. 
Protrusion of the cranial contents in shape of a sac covered by hair and scalp, and 
containing fluid and brain substance. Blindness ; idiocy. 



The faulty closure of the spinal canal causes a deformity called 
rachischisis or spina bifida. If the defect involves the spinal canal 



880 DISEASES OF THE NERVOUS SYSTEM. 

in its whole extent, there is rachischisis totalis. The vertebrae form 
a shallow canal in which lies the rudimentary spinal cord covered 
with a thin membrane. If the defect of the bony canal is only par- 
tial, there being a sac-like protrusion of the cord and its membrane, 
there is said to be a rachischisis cystica or spina bifida cystica or 
rachicele. 

Faulty development of the cranial bones with rudimentary brain 
is called cranioschisis (Fig. 202). If with the cranial defects there 
are defects of the bony vertebral canal, there is said to be cranio- 
rachischisis. 

If there are only partial defects in the cranial bones, with saccu- 
lated protrusion of the membranes of the brain (pia and arachnoid), 
with fluid in the sac, there is a meningocele. Meningo-encephalocele 
is a sac containing in addition the brain-substance. Encephalocele 
is a hernia of the brain and pia, no fluid being present in the sac. 

Spina Bifida. — Spina bifida or hydrorrhachis is a congenital 
deficiency in the vertebral laminae, through which the cord and its 
membranes protrude in the form of a sac containing fluid. The 
deformity is most frequently seen in the dorsolumbar, dorsosacral, 
and cervical portions of the vertebral canal. It rarely occurs in the 
middorsal region. It is generally single. It may occur both in the 
neck and in the lumbar region. 

The tumor may be small and only indicated by a fissure, or may, 
as in Broca's case, attain a circumference of 62 cm. It may be flat 
or pedunculated. The latter form is uncommon. The surface of 
the tumor may be smooth or lobulated and uneven. The lobulated 
forms indicate divisions in the interior of the sac. The skin cover- 
ing the sac may be very thin or glistening. It may burst during 
delivery, may be thick and vascular, or covered with cicatrices and 
granulating ulcers. In some tumors the subcutaneous tissue can be 
made out ; in others the skin is atrophic. In rare cases the tumor is 
composed of a mass of mucous tissue situated between the skin and 
dura mater. In the interior of this mass there is a small cavity 
(Kirmisson). Von Recklinghausen and Muscatello have demon- 
strated that the statement that the sac of the spina bifida is lined with 
dura mater is incorrect. Hildebrandt has, however, found cases in 
which the dura lined the sac. The pia and arachnoid line the sac. 
The fluid in the sac is serous and colorless or lemon-colored. It is 
alkaline in reaction, rich in salts, and contains sugar. If inflam- 
mation is present, blood is found in the sac. The fluid is either out- 
side the cord or in the central canal (Virchow). 

Classification. — Spina bifida is, with reference to the nature of the 
contents of the sac, divided into three forms : 

(a) Myelomeningocele, in which the fluid in the sac is situated 
between the cord and its membranes. 



DEFORMITIES OF SKULL AND SPINAL CANAL. 881 

(b) Meningocele spinalis, in which the inner surface of the sac 
is formed by the arachnoid and pia mater. 

(c) Myelocystocele, in which the fluid is situated in the central 
canal of the cord. 

Myelomeningocele. — The myelomeningocele forms a broad but 
not very prominent tumor, which may be found in the lumbosacral, 
cervical, thoracic, or sacral regions. At its base the tumor is red- 
dish, and is covered with fine, long hairs. This zone is from 1 to 
1^ cm. broad. In the centre of the tumor there is a reddish-brown 
velvety vascular area, the remains of the medullary vascular zone. 
The sac is formed of arachnoid and pia mater. Its interior is crossed 
by nerve-trunks. The cord is drawn outward and some nerves may 
arise from the prolongations of the cord. Accordingly, there is an 
accumulation of fluid in the meninges (hydromeningocele), with an 
accompanying hernia of the cord (myelocele). 

Meningocele Spinalis. — Meningocele spinalis is the rarest form 
of spina bifida. The sac is composed of pia and arachnoid. The 
latter may be much thickened. The opening into the vertebral canal 
if large may allow hernia of the cord. If the tumor is situated in 
the sacral region, the interior of the sac may contain the nerves of 
cauda equina. 

Myelocystocele, Hydromyelocele, or Syringomyelocele. — Myelo- 
cystocele, hydromyelocele, or syringomyelocele, is that form of spina 
bifida in which there is a dilatation of the central canal of the cord. 
The dura is lacking in the sac, which is lined with cylindrical epithe- 
lium. The spinal cord in part of its extent may be found in the sac, 
or may be found on the exterior wall of the sac and end there. It 
may break up into several bundles. In the interior the spinal nerves 
form a series of loops with their convexities posteriorly. They may 
return into the vertebral canal or may end in the sac. Spina bifida 
is a primary agenesis. The growth of the sac is due to inflamma- 
tory processes. 

Symptoms. — The tumor is the chief physical sign. It is situated 
in the median line or may be at one side. It is round or elliptical 
and covered with thinned or thickened skin (Fig. 203). In the 
centre of the myelocystocele is a depression which gives the tumor a 
tomato-like appearance. The tumor may be soft, hard, or fluctuating. 
The defective vertebral laminae may be discerned on palpation. The 
tumor enlarges and becomes tense when the patient assumes the 
upright posture, cries, or exerts himself. When the patient takes 
the recumbent posture it becomes smaller. It also does so at each 
inspiration. 

In some cases the functions of the individual are normal. In 
others, the mobility and sensibility of the lower extremities are 

50 



882 



DISEASES OF THE XEEVOVS SYSTEM. 



affected. Deformities of the foot similar to those seen in infantile 
paralysis are sometimes present. There may he incontinence of 
urine ancl faeces. There are sometimes trophic disturbances, such as 
perforating ulcers. These are of value in the diagnosis of lumbar 
tumors which are apparently lipomatous in their nature and are 
covered with hair (Kirmisson). In such tumors, disturbances of 
sensibility occurring with perforating ulcers and deformity and 
atrophy of a lower extremity are significant of spina bifida. 

Fig. 203. 








Spherical form of spina bifida lumbalis, ulceration at superior surface of tumor. 



Course. — Spina bifida if left to itself may grow to a large size, 
may burst or ulcerate, and cause death by pyogenic infection of the 
meninges and. cord tissue. In other cases a lineal ulcer discharges 
fluid and closes up several times in succession. In some cases of 
spina bifida the tumors remain stationary in size until late in adult 
life. In rare cases spontaneous cure results by inflammation of the 
pedicle of a pedunculated spina bifida. 

Diagnosis.- — The diagnosis of spina bifida is not difficult if what 
has been detailed of the anatomy and symptomatology is borne in 
mind. Muscatello gives the following characteristics of the various 
forms : 

Myelocystocele. — In myelocystocele there is a round tumor with 
a wide base. The tumor is lumbosacral, elastic, translucent, and 
fluctuating, and does not diminish on pressure. Pressure causes 
tenseness of the fontanelle. There may be scoliosis, lordosis, abdom- 
inovesical fissures, and deformity of the foot. 

Myelomeningocele. — In myelomeningocele there is a flat, soft, 
elastic tumor, either lumbar, sacral, cervical, or thoracic. It may 
be complicated by umbilical hernia, paralysis of the extremities and 
bladder, and deformity of the foot. 



DEFORMITIES OF SKULL AND SPINAL CANAL. 



883 



Meningocele. — In meningocele there is a sacral pedunculated 
translucent tumor, but no disturbances of mobility or sensibility. 

Spina Bifida Occulta. — Of considerable interest' is the form called 
spina bifida occulta (Fig. 204). In these cases there may be no 
tumor, the seat of the deformity being indicated by a depression or 
dimple. In other cases, as in that shown in the illustration from 
Kirmisson, there is a small tumor of doughy consistence on one of 

Fig. 204. 




s-, 



FB* 




Spina bifida occulta. 



the gluteal folds. The tumor may present an umbilication. Spina 
bifida occulta should be suspected in cases in which abnormal sacral 
depressions or tumors occur in connection with clubfoot deformities 
or congenital incontinence of urine or fares, or of both. 

Treatment.- The treatmenl of spina bifida belongs to the domain 
of surgery. The treatmenl by injections of Morion's tlnid (2 per 
cent. o( iodine, 6 per cent, of potassium iodide in glycerin) has been 
abandoned in favor of excision of the sac. 



SECTION XVI. 

DISEASES OF THE SKIN. 

The skin of the infant is exceedingly delicate in structure. After 
birth there is a physiological condition of desquamation, as a result 
of which the skin is very sensitive to a traumatism which in older 
children would be considered slight. In the newly born infant, such 
is the delicacy cf the structure of the skin that infection may occur 
when no lesion of continuity is apparent (cryptogenic). A rapid 
examination of the skin is the first step in making a full physical 
examination of an infant or child. The surface is first inspected 
from a distance, the color and the presence or absence of an eruption 
being noted. It is of the first importance to decide whether an erup- 
tion is acute or connected with constitutional taint (syphilis). An 
eczema may in a syphilitic infant have certain characteristic varia- 
tions of color which will at once lead the examiner to suspect consti- 
tutional disease. A familiarity with acute eruptions (exanthematic) 
is essential. These must be diagnosed or excluded before any treat- 
ment can be inaugurated. Forms of oedema must be differentiated 
from sclerema and myxoedema. and indurations of the skin from ele- 
vations. A papule may be elevated but not indurated. Since the 
skin of infants and children is exceedingly delicate, it will show indu- 
rations more distinctly than that of the adult. 

The Care of the Skin. — Stretching or harsh manipulation of the 
skin of infants will tear or traumatize it. Irritating soaps should 
not be used. The drying of the skin should be carried out gently. 
The skin in the groin and axilla should not be unduly stretched lest 
rhagades or fissures result. In powdering the skin, a fresh pledget 
of absorbent cotton should be used as a powder puff, and all the excess 
of powder blown off, lest caking result. In some infants the wearing 
of flannel or wool next to the skin causes irritation and eruptions of 
different varieties. Such infants should wear a very fine cambric 
or linen garment next the skin, and over this the woollen shirt. 

ECZEMA. 

Eczema is a very common affection in infancy and childhood. 

Some infants, otherwise in apparent health, suffer at times from 
a very mild eczema of the face, which appears chiefly on the cheeks, 
but which may also be present on the chin, forehead, and ears. The 

884 



ECZEMA. 880 

infants do not seem to suffer much, except that they scratch the erup- 
tion. The eruption is local. It may improve without treatment, 
but if there are conditions of traumatism and infection, it will grow 
worse. It is rarely moist, but, if scratched, it will bleed, and fissures 
or ulcers with bloody crusts will form. 

Another form of eczema is pustular and vesicular. The skin of 
the face has a red, angry look. Here and there patches of skin are 
covered with scabs ; in other areas the skin is moistened by a serous 
or seropurulent exudate. This eczema is usually also present on the 
hands and arms. If the malady has existed any length of time, there 
is considerable thickening of the skin of the hands. The head and 
scalp may be affected. 

Eczema is sometimes general. On the face, it is general and pus- 
tular; on the body, there are both the squamous and the pustular 
forms with all the various gradations between. There are crusts, 
rhagades, and areas of superficial loss of tissue. 

The infants scratch and are uneasy and restless at night, but the 
general health is excellent and the appetite and digestion are good. 
The weight increases. If the eczema is general, the infants some- 
times become puny. They scratch the eruption, constantly causing 
the surface to bleed. The body is sometimes one raw, suppurating 
surface. The lymph-nodes connected with the affected surface are 
enlarged. Such enlargements should be differentiated from those of 
pyogenic origin. 

A very troublesome form of eczema is the impetiginous or pus- 
tular variety. The pustules burst and leave the surface covered with 
dried crusts of pus. This form may affect any part of the body. Of 
especial interest, and in a class apart, is the so-called impetigo faciei 
contagiosa. This is a contagious pustular eczema. It affects by 
predilection the upper lip and the alse nasi. The pustules break down 
and leave dry crusts of a golden-yellow color. The anterior nares 
may be blocked up by these crusts. This variety of impetigo may 
in children spread over the whole surface and the extremities. I 
have seen it affect several children in a family. There can be very 
little doubt as to the infectious and contagious nature of the malady. 
Eichstedt, Lustgarten, and others have, with cocci obtained from the 
pustules, succeeded in inoculating the malady on the human subject. 

Intertrigo (eczema intertrigo) or erythema intertrigo is one of 
the forms of erythema which develop by maceration into an eczema. 
Intertrigo is found in the folds of the neck, axilla, and groin, in 
well-nourished, rather obese infants. It is at first acute, but may 
become chronic. There is at first a slight redness of the folds of the 
skin (erythema). If through neglect the epidermis is allowed to 
macerate, excess of secretion results ami the collected secretions 



886 DISEASES OF THE SKIN. 

decompose; the surfaces may become eroded, and ulcerations result. 
In some cases there are lineal ulcers in the groin. In others, the 
ulcers may become coated with a pseudomembrane. In rare cases 
actual necrosis of tissue results. Some anaemic infants present a ten- 
dency to rhagade formation, not only in the groin, but also around 
the anus and lips. The intertrigo may have the color of copper, 
instead of the bright-red hue of an ordinary eczema. In such cases 
there is always a possibility that the intertrigo may be of syphilitic 
origin. If there is no great p.anniculus of fat, and if with the inter- 
trigo there appear erythema and fissures between the toes, and glossi- 
ness of the skin on the plantar surface of the feet, there are additional 
grounds for assuming that there is a syphilitic element. Intertrigo, 
like other skin eruptions, may be accompanied by enlargement of 
the lymph-nodes leading from the region affected. In obese infants, 
the umbilicus may also be the seat of eczema, which results from the 
accumulation and decomposition of secretions. 

Seborrhoea capillitii is an eruption on the scalp of infants and 
children which is classified by Unna as a form of eczema. The scalp 
is covered with a coating of yellow or discolored sebum, which con- 
sists of fat, desquamated epithelium, and hair. If allowed to accu- 
mulate, it is sometimes of considerable thickness and may be detached 
from the scalp. It then leaves a slightly reddened surface, which 
may bleed. In a short time the scalp may become glossy, and a new 
layer of the fatty secretion may form. This process may continue 
until the second or third year. This seborrhoeic eczema has some- 
times a cheesy odor. 

Seborrhoea of the umbilicus has been mentioned. In infants and 
children there may also be seborrhoea of the prepuce. There are, in 
neglected cases, secretion and aphthous ulcerations of the folds be- 
tween the glans and the prepuce and in the folds of the prepuce. 

Of great interest to the physician is a form of intertrigo or 
eczema found on the buttocks and between the nates of infants. It 
occurs in infants who are not kept dry and whose urine decomposes 
easily if the diapers are not changed frequently. This is a most 
troublesome form of eczema. The nates are at first red, the skin 
then becomes glossy and brittle, and there may be extensive desqua- 
mation of the surface. This form of eczema or intertrigo may dis- 
appear under treatment, only to return if precautions as to cleanliness 
and dryness are not observed. Some of the children suffer from 
enuresis, and contract the affection through maceration of the skin 
by the decomposed urine, or from unclean diapers. 

Etiology. — The etiology of eczema is still obscure. The condi- 
tions in infancy and childhood are favorable to the development of 
skin affections. The delicacy of the skin, its constant exposure to 



ECZEMA. 887 

dirt and to irritants of all kinds, and changes of temperature, are 
etiologically important. All the children of a family may suffer 
from eczema. In such instances, there is a real hereditary tendency 
to the disease. The parents are sometimes similarly affected. The 
influence of diet in causing eczema is not yet understood, hut some 
authors are firmly convinced of the deleterious effects of certain arti- 
cles of food. I have known urticaria to be caused by eating oatmeal 
and fruits, such as strawberries, and urticaria may be the beginning 
of eczema. In most cases eczema cannot be attributed to articles of 
diet. It is possible that in certain children the processes of metabo- 
lism are at fault. Though it has not been proved that all eczema is 
of an infectious character, there can be but little doubt that many 
forms are caused by the deleterious action of micro-organisms on the 
skin (ITnna). In favor of this theory is the fact that in many para- 
sitic skin affections eczema is an accompanying condition. 

Treatment. — The treatment of eczema is exceedingly difficult. 
The external causes of irritation should be immediately removed. 
Attention to cleanliness is alone sometimes sufficient to cure an eczema. 
If woollen clothing is irritating to the skin, a substitute should be 
found and cotton or cambric should be worn underneath the wool. 

The diet should be regulated. This is not an easy task, since it 
is not known what articles of diet produce eczema. If the infant is 
at the breast, the diet of the wet-nurse and her daily habits should be 
regulated. Even when the nurse takes simple food, and the milk is 
flawless, the infant may suffer from eczema. If the nurse is addicted 
to the use of beer, or vegetables, such as asparagus, the quality of the 
milk may be affected. The diet of a wet-nurse should not be changed 
more often than is necessary, else the secretion of milk may cease. 
If the wet-nurse has a rheumatic or gouty tendency, it is wise to 
change nurses. On the other hand, an infant may be overfed and 
excessively fat. In that case the intervals between nursings should 
be lengthened. To attempt to change the percentage of fat in the 
milk is not only of questionable utility, but is not always feasible. 
If the nurse is constipated, the bowels should be regulated, and she 
should take abundant exercise. Artificially fed infants are still more 
difficult to manage. If the infant is thriving, interference with the 
food percentage is not always clearly indicated. Artificially fed 
infants may also be overfed or the percentage of fat or proteids may 
be too high. There may, however, be eczema even when the compo- 
sition of milk is proper for the infant, age and weight being taken 
into consideration. 

If there are acidity of the stomach, excessive Hat us. constipation. 
or green stools, regulation of diet is of move practical utility. In 
such cases it may cause the eczema to diminish. It" there is stomach 



888 DISEASES OF THE SKIN. 

acidity, an alkali (lime-water) should be added to the food. Con- 
stipation and flatulence should be remedied. If the infant passes 
urine with urates to such an extent as to cause a red deposit on the 
diaper, small doses of bicarbonate of sodium should be administered 
and lime-water should be mixed with the food. 

Changes of diet are helpful only in those forms of eczema which 
are either general or disseminated over different parts of the surface. 
Seborrhoea and intertrigo are purely local affections, and are not 
influenced by changes of diet. 

Local treatment is chiefly relied upon to improve the condition 
of the skin. In the acute or subacute forms soothing applications 
are utilized. The chronic forms are irritated into a state of reaction, 
and then treated like acute eczema. The treatment of acute local 
eruptions, such as intertrigo, consists first in keeping the parts scru- 
pulously clean. After the bath the folds of the skin are mopped, 
dried carefully, and powdered, the excess of powder being blown off. 
This alone is sometimes sufficient to cure a slight intertrigo. Dusting- 
powders which contain carbolized preparations irritate the skin. A 
good powder has the following composition : 

]£ Zinci oxidi 3iv (16.0). 

Amylum ^ij (60.0).— M. 

Equal parts of zinc and starch powder make an equally good powder. 
These ingredients should be ground to an impalpable powder. In 
the severer forms of intertrigo, the parts should first be anointed with 
ointment having the following composition : 

~fy Eesorcin gr. ij-iv (0.12-0.24). 

Adeps benzoinati 3J (30.0). 

M. — The lard should be washed. 

The ointment should be removed from the folds of the skin with 
a pledget of lint. The skin after being thus left in a slightly greasy 
state is powdered, the excess of powder being blown off. If there 
are lineal ulcers in the groin, they should be lightly touched once 
a day with a 2 per cent, solution of nitrate of silver, to promote 
granulation. The ointment should then be applied with a small piece 
of lint. 

In squamous eczema which is a red or pustular eczema of the face, 
scalp, and hands, the first question that arises is whether the patients 
should be bathed. An infant should be kept clean, and there is only 
one satisfactory method, and that is the bath. If there is eczema of 
any part of the surface, the bath water may be liberally impregnated 
with bran. A gauze bag filled with a measure of bran is put into 
the bath and the bag is squeezed until the water becomes turbid. If 
a minute quantity of bicarbonate of sodium is added to a bath pre- 



ECZEMA. 889 

pared in this way, the effect on general eczema is decidedly soothing. 
The skin is gently dried after the bath and powdered. If the whole 
trunk is involved, it is best that the parts of the surface should be 
treated in succession. The face or an arm is covered with an oint- 
ment applied by means of a piece of lint, or the ointment is simply 
rubbed on the skin after the bath. It is not feasible to wrap the 
whole body in lint and ointment ; with certain drugs, such as resorcin, 
absorption would occur. The ointments should be applied after the 
crusts and pustular accumulations have been removed. All oint- 
ments should be made up with washed benzoinated lard. Vaseline 
is very irritating to some forms of eczema. Of the emollient and 
soothing ointments, diachylon, zinc, and bismuth hold a leading place. 
A very good ointment for general use in rhagades and squamous 
eczema is the following, which is one of Kaposi's formulas : 

K Kesin. benzcea pulv ^j (4.0). 

e Axung.porc |v (150.0). 

Digere cola adde. 

Zinc, oxidat *j (30.0). 

M. et ft. unguentum. 

If made up properly, this is an excellent cosmetic ointment for use 
in dry eczema. If the skin is dry and thickened, a 1 per cent. 
/?-naphthol applied twice daily will soften it. If this treatment proves 
irritating, a zinc ointment may be applied immediately afterward. 
In many cases of chronic eczema Lassar's paste is beneficial : 

li Acidisalicyl gr. xxx (2.0). 

Zinci oxidat. | -- gj (300) 

Vaselin ^jss (45.0). 

M. et ft. paste. 

The following ointment is also excellent : 

R Acidi salicylici gr. xv (1.0). 

Ung. zinci oxidi 31J (60.0). — M. 

The tar salves and mixtures are useful in cases of chronic eczema 
in which there is little or no moisture : 

H 01. nisei 5jj (4.0). 

Ungt. zinci ox gj (30.0), 

M. — For external use. 



or 



R 01 ; fa gi Jjijss (10.0). 

Glycerin zj (4.0^ 

Ung. diachylon ^jss (45.0). 

Balsam. Peru Wnx (2.0).— M. 



890 DISEASES OF THE SKIN. 

In cases of red eczema of the face, the ointment is best applied 
on a mask made of lint. 

In that form of intertrigo which results from the irritation of 
urine, the condition of the diaper is frequently the chief source of 
trouble. It is often damp or too thin. As a result, whenever the 
infant passes urine, the diaper becomes saturated with it and decom- 
position takes place. A piece of absorbent gauze as large as the 
diaper should be placed next the skin, and renewed whenever it 
becomes moistened. The skin is dried and the ointment applied on 
the gauze. Intertrigo is quickly cured by this treatment. 

Treatment of Seborrhcea of the Scalp. — The accumulated sebum is 
moistened with oil, or a piece of lint moistened with olive oil or any 
indifferent oil is applied at night. In the morning the crust of sebum 
will have softened sufficiently to allow of its removal with green soap 
and water. After the parts are well cleaned, a salicylated ointment, 
0.5 to 1 per cent., is applied daily. The ointment should be spar- 
ingly applied in order that it may not irritate the parts. Seborrhoea 
should be treated for some time after it is apparently cured, or it will 
return. In older children who have abundant hair, the seborrhoea 
accumulates at the roots and the scalp has an odor. The head should 
be thoroughly shampooed once a week; after the shampoo, an exceed- 
ingly small quantity of cosmetic hair oil should be applied to the scalp 
once a day. 

ERYTHEMA MULTIFORME. 

(Erythema Nodosum; Erythema Exudativum.) 

Erythema exudativum is divided into two forms. The acute 
form includes erythema multiforme and nodosum, and is an acute 
infectious disease (Lewin). The exudative form occurs frequently 
in infants and children. Of 40 of my cases, 10 were under two 
years of age. 

The form of erythema known as erythema nodosum begins with 
general malaise and sometimes with fever, which may be quite high. 
There is pain in the joints and over the areas affected. These areas 
are raised and are purple or bluish; the skin is tense and the parts 
affected are very painful. The nodes vary in size. They first appear 
chiefly on the extensor surface of the tibiae. The extremity some- 
times looks as if it had been beaten. This form of erythema is per- 
haps allied to hemorrhagic diseases, such as peliosis. In a case of 
peliosis rheumatica which I saw recently there were erythematous 
and painful nodules on the hands. Antitoxin may cause exudative 
erythema. As is well known, such toxic infection also involves the 
joints. The symptoms are fever, pain in the joints, and extensive 



FUBUNCULOSIS. 891 

erythema nodosum. I have seen such a case in a subject, who had 
received an immunizing injection. Within six hours, the legs, knees, 
and thighs were swollen and the seat of this peculiar erythema. 

French writers speak of the frequency of cardiac disease in ery- 
thema nodosum, and of its relationship to rheumatism. I have care- 
fully studied 40 cases for signs of cardiac disease, and could find 
only 3 cases with systolic murmur at the apex. I have recently seen 
2 others. In my opinion, true endocarditis is not a very common 
complication of erythema nodosum. In only one case did the mur- 
murs appear to be serious. The disease lasts only a few days, but 
there may be relapses. 

The second form of chronic erythema resembles the acute form. 
The nodules are flat and deep, and are not raised much above the 
surface. They appear chiefly on the lower extremities of badly nour- 
ished children. They are less painful than in the acute form. After 
a time they disappear, leaving no sign of their presence. 

Treatment. — Cases of erythema of the acute form are treated with 
sodium salicylate and a diet of milk at first, fruit-juices and beef- 
juice being given later, and local applications of oil of wintergreen 
to the painful areas. 

FURUNCULOSIS. 

(Folliculitis Abscedens or Perifolliculitis Abscedens. — Escherich.) 

This affection of the skin is very common in infancy and child- 
hood, and occurs chiefly in badly nourished, marantic babies, who 
suffer from gastro-enteric and pulmonary infections. The disease is 
due to an invasion of the deeper layers of the skin by staphylococci. 
These have been found in the pus and in the sweat and sebaceous 
glands of the skin (Escherich). In the mild forms of furunculosis 
there are one, two, or more furuncles on the forehead, scalp, occiput, 
and neck. Sometimes the furuncles are large and the skin is riddled 
with them, but as a rule they do not communicate with one another. 
In aggravated cases, furuncular abscesses occur on the trunk and on 
the upper and lower extremities. When the furuncles or boils be- 
come very numerous, they play a leading role. Many children in 
institutions succumb to this affection. The condition closely resem- 
bles a form of sepsis. 

Treatment. — The treatment of these cases is simple. I have ad- 
ministered alkalies, such as bicarbonate of sodium, internally. The 
effect on the general process is excellent. I have also given sulphide 
of calcium in grain 4 doses (0.03) with good effect. The infant is 
bathed in bran daily. Too many of the abscesses should nor be 
opened at once, and they should not be opened until they point and 



892 DISEASES OF THE SKIN. 

the skin over them becomes reddened. If they are opened earlier, 
the results are not so good. After the abscesses are opened, the pus is 
expressed and a moist dressing applied. The abscesses heal easily. 
As in other septic affections, the patients should be stimulated and 
carefully fed. Small furuncles appearing only on the face need not 
be opened. The application of a 2 per cent, salicylated ointment 
twice daily softens the pustules and causes the contents to be dis- 
charged. I have seen most brilliant results from the use of vaccines 
in cases above described. The vaccines should be prepared from the 
pus of the furuncle or abscess. 

SUDAMINA. 

(Miliaria Alba; Miliaria Rubra.) 

Sudamina is an affection occurring in infants and children during 
very warm weather. In the form called miliaria alba the epidermis 
at the openings of the sweat-glands is raised by a minute serous exu- 
date and small vesicles are formed. There is no inflammation of 
the skin. In a second form, the same process takes place, with the 
presence of a minute focus of inflammation and redness at the open- 
ing of the glands. Some of the vesicles are pustular. There are 
also numerous papules of eczema. There is a slight infection of the 
skin about the opening of the sweat-glands. Both these conditions 
are irritating, but in no way serious. The skin should be kept scru- 
pulously clean and dried with powder. Woollen fabrics should not 
be worn next the skin. If the condition becomes severe, bran baths 
and a bland zinc or diachylon ointment should be used. Sudamina 
of both varieties are met with in scarlet fever dermatitis. 

DERMATITIS EXFOLIATIVA. 

(Bitter von Eittershain.) 

This affection is peculiar to the newborn infant. Hitter in 1878 
described an epidemic. In 1895 Escherich published an account of 
a small outbreak in Gratz. 

Nature and Etiology. — It was first suspected by Ritter to be one of 
the septic infections of the newly born infant. His view has lately 
been supported by Escherich. 

Occurrence and Symptoms. — The disease appears from a few days 
to two weeks after birth. It usually occurs in poorly nourished in- 
fants, but may affect apparently healthy infants of normal weight. 
Boys are more frequently affected than girls. The affection is pre- 
ceded by the appearance of a diffusely red erythematous or dark 
swelling of the general surface. The skin is thickened, soft, mac- 



CONGENITAL ICHTHYOSIS. 893 

erated, and velvety to the touch. The epidermis can be moved on 
the corium beneath. The pressure of the clothing or bedclothes may 
also produce this effect. Minute vesicles appear, and coalesce to 
form larger vesicles or bullae. Vesicles or bullae of large size which 
may be either partly filled with serum or empty are formed. They 
are never tense, and finally open or tear, leaving the red moist 
corium exposed. The surface of the body has a beefy-red color, and 
is covered here and there with patches of dry, adherent epidermis ; in 
other areas the corium is exposed. There are rhagades at the angles 
of the mouth and on the trunk. The upper extremities become 
affected later than the lower ones. Whole areas of the trunk and 
body are denuded of epidermis. After the vesicles burst and leave 
the corium exposed, the epidermal layer of the skin is still adherent 
in places, while the desquamated skin is rolled up into cord-like masses 
and hangs loosely exposed. If recovery takes place, the corium be- 
comes covered with a delicate epidermis, which gradually assumes the 
normal pinkish-white hue. Some cases may run an afebrile, others 
a febrile course. 

Course and Prognosis.. — A few of the cases recover. Ritter lost 50 
per cent, of his cases, and Escherich 90 per cent. The infants may 
die from the sixth to the tenth day or after the third week, when 
much of the skin has undergone retrograde changes. The cases may 
show umbilical infection or bronchopneumonia, pointing to the septic 
nature of the disease. 

Treatment. — The infants are kept warm by artificial means, such 
as warming bottles or an incubator. They are not bathed. The skin 
is protected by the application of bland salves or gauze moistened 
with a mixture of linseed oil and lime-water (Escherich). Some 
physicians add a small quantity of salicylic acid to the salves. As 
soon as the skin has become dry, Lassar's paste and powdered zinc 
are applied. 

CONGENITAL ICHTHYOSIS. 

(Cutis Sebacea.) 

Ballantyne gives an exhaustive description of this affection, which 
is really a perpetuation of a foetal condition into post-natal life. The 
foetal skin has a tendency to seborrhoea. This is apparent after birth, 
and is evident during infancy as seborrhea of the scalp. The sebor- 
rhoea may affect different parts of the body and may form thin shining 
scales on the surface of the skin. There may be secondary eczema. 
The mild forms may, with ordinary cleanliness and the application of 
bland salves, disappear a few weeks after birth. The form described 
by Hebra and Kaposi as ichthyosis congenita is an extreme example 






894 DISEASES OF THE SKIN. 

of the tendency of the foetal skin to the formation of sebum or vernix. 
The increased secretion continues after birth. The infant appears 
to be covered with a horny mass which almost envelops it. 

This parchment-like covering is absent at the mouth, eyes, anus, 
and on the scalp. The surface is firm and of a yellow or brownish- 
red tint (Escherich). The hardness and brittleness of the skin 
render motion painful. The infant is enclosed as if in case-armor. 
The face has a mask-like expression. The skin is broken in places, 
especially at the joints. At these fissures the true skin is seen. At 
the broken spots, the sebum is seen to be composed of lamella?, from 
the posterior aspect of which project warty excrescences corresponding 
to the lanugo and openings of the sebaceous glands. These may be 
removed from the skin. If the infant lives, the layers of sebum are 
thrown off gradually, and the skin is left with a general seborrhoea 
of the ordinary type. Escherich predicts a favorable course in most 
of these cases, but some die shortly after birth. Pathologically there 
is a great thickening of the rete Malpighii ; the corium shows no 
changes ; the sebaceous glands are atrophied or the seat of fatty degen- 
eration; the sudoriparous glands are normal. After the layers of 
horny sebum have peeled off, the skin underneath appears pink or 
red or shining, and is covered with seborrhceal scales. 

Treatment.- — The treatment consists in the application of emol- 
lients and in washing the skin daily or bathing the infant in perman- 
ganate of potassium (grains xv (1.0) to the bath water). Salicylic 
and boric ointments are applied after the baths. 

PEMPHIGUS NEONATORUM. 

Pemphigus neonatorum is a contagious, infectious disease of the 
skin occurring in the newborn infant. It has also been observed 
later in infancy. It usually appears at the end of the first or second 
week, and affects the whole surface, except the palms of the hands 
and the soles of the feet. There appear on the surface of the trunk 
and extremities small and large vesicles containing cloudy serum. 
These burst and leave a round patch of skin, which dries and is 
covered with yellowish scales. The vesicles may attain the size of 
bulla?. They may be discrete or involve the whole body, so that the 
surface is after a time denuded of the epithelial layer. The disease 
may in the beginning be confounded with dermatitis exfoliativa. 
The vesicles may appear in crops; the recurrences may extend over a 
period of from two to four weeks. 

There are two forms, in one of which the disease is mild ; in the 
other it runs a malignant course, and from the outset large areas of 
skin are denuded of epithelium by the bursting of enormous bulla?. 



PEMPHIGUS NEONATORUM. 895 

The infants pass into an asthenic condition, refuse nourishment, and 
die in a few days. 

Etiology. — Both forms appear in epidemics. The disease occurs 
sporadically. The essential cause is still obscure. Strelitz, Demme, 
Almquist, and Escherich have isolated a white staphylococcus from 
the serum of the vesicles. Its role as an etiological factor is not as 
yet understood. Escherich is inclined to class this form of pemphigus 
with other infectious skin diseases, such as the impetigo of Wilson 
or Bockhart, and folliculitis abscedens, in which certain conditions 
favor serous infiltration of the horny layer of the skin and extensive 
desquamation from the corium. He believes the exciting cause to 
be the pus cocci found in other forms of impetigo. Escherich has 
suggested the use of the name "Impetigo Bullosa Neonatorum or 
Infantum " for this affection. 

Prognosis. — The prognosis is favorable if the process confines itself 
to the superficial layers of the skin. If the deeper layers are attacked, 
abscesses and general sepsis result. 

Treatment. — Escherich recommends that the affected parts be 
washed with soap and water, and dressed with a 2 per cent, ointment 
of white precipitate. Baths are not given. Those who are inter- 
ested in the epidemiological aspect of this disease will find the mono- 
graph of Richter exhaustive. 



INDEX 



Abdomen, boat-shaped, in meningitis, 44 
contour of, in tumor, 44 
distension of, in ascites, 44 
examination of, 44 
free fluid in, 44 
inspection of, 44 
in intussusception, 44, 45 
pain in, 45 
palpation of, 44 
polypoid tumors in, 45 
retracted in septic peritonitis, 44 
tenseness of, in colic, 44 
tumor of, dyspnoea in, 615 
tympanites of, liver dulness in, 44 
in peritonitis, 44 
Abdominal pain, 45 

in appendicitis, 45 
in pericarditis, 45 
in pleurisy, 45 
in pneumonia, 45 
typhoid fever, 318. See Ty- 
phoid Fever 
Abscess of brain in scarlet fever, 275 
of breast, 128, 129 
cerebral, sudden death in, 21 
metastatic, in arteritis umbilicalis, 
210 
in phlebitis umbilicalis, 211 
perinephritic, diagnosis of, from 

acute appendicitis, 550 
peri-cesophageal, 491 
diagnosis of, 491 
etiology ot, 491 
prognosis of, 492 
symptoms of, 491 
treatment of, 492 
periproctitic, in dysentery, 532 
rectal exploration in, 46 
retro-oesophageal, 491 
retropharyngeal, 585 
diagnosis of, 587 
diphtheria and, 389 
etiology of, 586 
in follicular amygdalitis, 590 
forms of, 585 
frequency of, 586 
idiopathic, 585 
lymph-nodes and, 5S5 
onset of, 586 
prognosis of, 587 
in scarlet fever, 271, 276 
sudden death in, 20 
symptoms of, 586 
treatment of, 587 
voice in, 587 

57 



Abscess of scalp, diagnosis of, from 
cephalhematoma, 235 
of skin in scarlet fever, 272 
subcutaneous, in typhoid fever, 327 
subphrenic, 672 

diagnosis of, 673 

gas in, 673 

metallic tinkle in, 673 

physical signs of, 673 

simulating enlargement of 

liver, 562 
succussion in, 673 
treatment of, 673 
visceral displacement in, 670 
of thymus gland, 729 
Acetone breath in cyclic vomiting, 505 
in diabetes mellitus, 712 
in urine, 33 
Acetonuria, 33 
Achondroplasia, 250 
Acids, fatty, in human milk, 93 
Acorn cocoa, 118 

composition of, 119 
Addison's disease, 753 

etiology of, 75.3 
pigmentation in, 754 
symptoms of, 753, 754 
treatment or, 754 
Adenitis, acute, 716 

diagnosis of, 716 

from infectious parotitis, 
717 
etiology of, 716 
frequency of, 716 
pyogenic infection and, 716 
symptoms of, 716 
treatment of, 717 
facial expression in, 39 
retropharyngeal, enlargement of 
lymph-nodes in, 715 
in scarlet fever, 276 
tuberculous, diagnosis of, from 
Hodgkin 's disease, 747 
Adenoid growths, 579 
age and, 5S0 
bronchitis and. 582 
deafness and, 581 
diagnosis of. 583 

from nasal polypi, 583 
emphysema of long and, 602 
enlargement of lvmph-nodes 

in. 715 
etiology of, 3 SO 
examination in. method of, 584 
facial expression in. 39 
lymphatism and. 580, 581 

897 



898 



INDEX. 



Adenoid growths, mouth-breathing and, 
581 
occurrence of, 579 
pavor nocturnus and, 822 
prognosis of, 584 
rhinitis and, 580 
situation of, 580 
snoring and, 581 
speech and, 581 
symptoms of, 580 
treatment of, 584 

operative, 584, 585 

contra-indications for, 

585 
indications for, 584 
varieties of, 582 
tumors of umbilicus, 207 
vegetations, 579 
Adenomata of rectum, 554 
Adenopathy, syphilitic, 715 
Adherent pericardium, 681 
Agenesis corticalis, 849 
Agglutinins in human milk, 97, 9S 
Air, open, 60 

Albinism, nystagmus in, 40 
Albumin in cerebrospinal fluid, 77 
in cow's milk, 102 
role of, in nutrition, 83, 84 
in urine, 33 
Albuminoids, digestion of, in newborn, 

169 
Albuminuria in acute gastro-enteric in- 
fection, 520 
cyclic, 770 

diagnosis of, from nephritis, 

772 
etiology of, 771 
prognosis of, 772 
symptoms of, 771 
treatment of, 772 
urine in, 771 
in follicular amygdalitis, 590 
in influenza, 344 
lordotic, 770 
in mumps, 371 
orthostatic, 770 
postural, 770 
in scarlet fever, 278 
Alcohol in human milk, 97 
Alexins in human milk, 17, 88, 89, 94. 95 
Allenbury's food, 120 
Allergistic reaction in tuberculin test, 

426 
Amaurosis in measles, 304 

in. scarlet fever, 279 
Amaurotic idiocy, 837 
Amblyopia, infantile, nystagmus in. 40 

in typhoid fever, 328 
Amoebic colitis, 534 
dysentery, 534 
Amorphism, dental, in syphilis, 473 
Amygdalitis, follicular, 589 
age and, 589 
albuminuria in, 590 
diagnosis of, 590 
duration of, 590 



Amygdalitis, follicular, endocarditis in, 
590 
etiology of, 589 
nephritis in, 590 
otitis in, 590 
prognosis of, 590 
retropharyngeal abscess in, 

590 
rheumatic cases of, 590 
symptoms of, 589 
tonsils in, 589 
treatment of, 590 
lacunar, 589 
Amylase in human milk, 94 
Amylolytic ferments in newborn, 169 
Anaemia, 736 

acquired, 736 

congenital, 736 

in cystitis, 795 

enlargement of lymph-nodes in, 716 

essential, 736 

in habitual constipation, 539 

infantum pseudoleukaemica, 739 

enlargement of liver in, 
562 
lymphatica, 747 
pernicious, 752 

blood in, 752 
primary, 736 

progressive, in uncinariasis, 559 
pseudoleukaemic, 739 
blood in, 741 
bone-marrow in, 740 
diagnosis of, 742 
etiology of, 740 
kidney in, 740 
liver in, enlargement of. 740. 

741 
lymph-nodes in, 741 
pathology of, 740 
rachitis and, 741 
skin in, 740 

spleen in, enlargement of, 740 
symptoms of, 740 
treatment of, 742 
in rachitis, 245 
scarlet fever and, 280 
secondary, 737 
simple, 737 

blood in, 737, 738 
etiology of, 737 
haemoglobin in, 738 
hydrsemia in, 737 
symptoms of, 737 
Anaemic cardiac murmurs, 705 
Anaesthesia, sudden death in, 22 
Anchylostoma duodenale, 558 
Aneurysm, sudden death in, 20 
Angina, 591 

catarrhal, 589 

in chronic valvular disease of 

heart, 703 
membranous, in scarlet fever, 270 
in scarlet fever, 267, 270 
Anorchidism, 181 
Anorexia in hysteria, 804 






INDEX. 



899 



Anterior poliomyelitis, 861 
Antitoxin, diphtheritic, 397 

eruptions, diagnosis of, from mea- 
sles, 307 
in human milk, 97, 98 
Antipyretics, administration of, 63, 64 
Anus, fissure of, 553 

constipation in, 553 
diagnosis of, 553 
symptoms of, 553 
in syphilis, 553 
treatment of, 553 
prolapse of, 552 
spasm of, 554 

treatment of, 554 
Aortic cardiac murmurs, 705 
Aphasia in acute encephalitis, 860 
in scarlet fever, 279 
in typhoid fever, 328 
Aphthae, Bednar's, 62, 476 

diagnosis of, from diphtheria, 395 
Aphthous stomatitis, 478 
Apncea in laryngismus stridulus, 817 
Apoplexy, sudden death in newborn 

and, 180 
Appendicitis, abdominal pain in, 45 
acute, 547 
catarrhal, 548 

symptoms of, 548 
diagnosis of, 549 

from intussusception, 545 
from lobar pneumonia, 551 
from perinephritic ab- 
scess, 550 
from tuberculous perito- 
nitis, 550 
from typhoid fever, 551 
fever in, 550 
frequency of, 547 
gangrenous, 549 

symptoms of, 549 
McBurney's point in, 550 
pain in, 550 
palpation in, 549 
percussion in, 550 
perforative, 548 

symptoms of, 548 
prognosis of, 551 
rectal examination in, 550 
suppurative, 548 
symptoms of, 548 
tympanitis in, 550 
varieties of, 547 
chronic, 551 

symptoms of, 551 
treatment of, 552 
colic in, 509 
empyema and, 652 
diagnosis of, from gonococcal peri- 
tonitis, 571 
from pneumococcal peritonitis. 

572 
from typhoid fever, 330. 332 
vomiting in, 507 
Appendix vermiformis, 547 
anatomy of, 517 



Appendix vermiformis, palpation of, 
547 
position of, 547 
size of, 547 
Areas, painful, in spine, 47 
Armour's beef -extract, 118 
beef-juice, 115 
wine of peptone, 115 
Arnold's sterilizer, 107 
Arrhythmia, 30 

in myocarditis, 708 
in newborn, 168 
Arrowroot, composition of, 115 
gruel, 115 

preparation of, 115 
Arterial murmurs, accidental, 706 
Arteriosclerosis, hypertrophy of heart 

in, 709 
Arteritis umbilicalis, 209 

abscesses, metastatic in, 210 
course of, 210 
etiology of, 209 
Pfennig's symptom in, 210 
pathology of, 209 
prognosis of, 210 
symptoms of, 210 
Arthritic pains in chorea, 825 
Arthritis, bronchopneumonia and, 642 
deformans, 463 
in dysentery, 532 
rheumatoid, 463 

lymph-nodes in, 464 
onset of, 463 
prognosis of, 464 
symptoms of, 463 
treatment of, 464 
scarlet fever and, 277 
in typhoid fever, 328 
vulvovaginitis and, 792 
Arthrogryposis, 808. See Tetany 
Articular rheumatism, acute, 459* 
Artificial infant-feeding, 133 

respiration, 195 
Ascarides lumbricoides, 556 
Ascaris lumbricoides, peritonitis and, 

569 
Ascites, 45, 567 
chylous, 568 

etiology of, 568 
diagnosis of, 568 

from cysts of peritoneal cav- 
ity, 568 
from tumors of peritoneal 
cavity, 568 
distension of abdomen in. 44 
dyspnoea in, 615 
etiology of, 568 
forms of, 568 
treatment of. 568 
Asphyxia in congenitaUy weak infants, 
IDS 
in newborn . 193 

after-treatmenl in, L97 
artificial respiration in. 195, 196 
bath in. 195 
definition of, 193 



900 



INDEX. 



Asphyxia in newborn, diagnosis of, 
195 
from acute fatty degener- 
ation of newborn, 221 
from cerebral hemor- 
rhage, 195 
etiology of, 193 
extra-uterine, 193, 197 
intra-uterine, 193 
pathology of, 194 
prognosis of, 195 
symptoms of, 194 
treatment of, 195 
Asthma crystals in fibrinous bronchitis, 
601 
dyspnoea in, 614 
in emphysema of lungs, 604 
thymic, 729, 816 
Ataxia, Friedreich's, ataxic gait in, 50 
patellar reflex in, 49 
hereditary, 858 

diagnosis of, 859 

from tabes, 859 
muscular power in, 858 
nystagmus in, 858 
prognosis of, 859 
sensory disturbances in, 858 
symptoms of, 858 
treatment of, 859 
in typhoid fever, 328 
Ataxic gait, 50 
Atelectasis, 198 
acquired, 198 
auscultation in, 199 
in bronchopneumonia, 634 
compression, 198 

in congenitally weak infants, 184 
convulsions in, 200 
diagnosis of, 200 
dyspnoea in, 199 
etiology of, 198 
in measles, 302 
obstructive, 198 
palpation in, 199 
percussion in, 199 
prognosis of, 200 
rales in, 200 
sudden death from, 19 
symptoms of, 199 
treatment of, 200 
Athetoid movements, diagnosis of, from 

chorea, 828 
Athetosis in infantile cerebral palsy, 

848 
Athrepsia, 260 
Athyreosis, 718, 722 
Atresia, congenital, of oesophagus, 490 
Atrophic paralysis, acute, 861 
Atrophy of muscle in acute poliomve- 
iitis, 870 
infantile, 260 

carbohydrates in, 261 
cereals in, 261 
etiology of, 260 
fats in, 261 
pathology of, 261 



Atrophy, infantile, symptoms of, 262 
treatment of, 263 
of liver, acute yellow, 567 
muscular, 49 

in diphtheria, 49 
facio-scapulo-humeral, Dejer- 
ine type of, 873 
Landouzy type of, 873 
in infectious diseases, 49 
in joint-affections, 49 
in neuritis, 49 
in poliomyelitis, 49, 870 
progressive muscular, Erb's type, 
872 
juvenile form of, 872 
Auricular septum, congenital defects 
of, 689 
ventricular septum, congenital de- 
fects of, 689 
Aura in epilepsy, 820 
Auto-infection in sepsis in newborn, 202 

B 

Babinski's reflex, 49 

in cerebrospinal meningitis, 

352 
in tuberculous meningitis, 435, 
439 
Bacillary infection of human milk, 97 
Bacilluria, 796 

Bacillus coli communis in cystitis, 793 
diphtheriae, 379 

of Klebs-Loffler in diphtheritic rhi- 
nitis, 578 
mesentericus vulgatus in cows' 

milk, 105 
potato, in cows' milk, 105 
subtilis in cows' milk, 105 
Bacteria in cerebrospinal fluid, 76 
in human milk, 94 
of mouth, 62 
newborn and, 17, 18 
Bacterium coli communis in acute peri- 
tonitis, 569 
lactis aerogenes in cows' milk, 105 
Bad habits, 805 
Balanitis, enlargement of lymph-nodes 

in, 715 
Barley, dextrinized, 114, 158 

Eobinson's patent, 114, 158 
water, 114 

in gastro-enteritic disturb- 
ances, 114 
preparation of, 114 
Barley-gruel, 157 

preparation of, 158 
use of, 157 

in newborn, 157, 158 
Barlow's disease 254. See Scorbutus, 

infantile 
Bartholini's glands, metastasis of 

mumps to, 371 
Basedow's disease, facial expression in, 

38 
Basilar meningitis, 432 



INDEX. 



901 



Bath, Brand, 65 

in congenitally weak infants, 190 
daily, 54 

temperature of water for, 54 
time for, 54 
first, 53 

drying after, 54 
rapidity of, 54 
temperature of room for, 53 

of water for, 53 
water for Oo, 54 
full, 65 

in pneumonia, 65 
in scarlet fever, 65 
in typhoid fever, 65 
hardening with, 55 
in premature infants, 55 
reaction in, 55 
sponge, 64, 65 
Bed, 58, 59 

mattress of, 59 
pillow of, 59 
Bednar's aphthae, 62, 476 
etiology of, 476 
in sepsis in newborn, 203 
treatment of, 476 
Beef-broth, 118 

composition of, 118 
Beef-extracts, 117 

composition of, 118 
varieties of, 118 
Beef -juice, composition of, 115 

varieties of, 115 
Beer, effect of, on human milk, 96 
Bell's paralysis, 851 
Benger's food, 120 
Biedert's mixture, 133, 134 
Bilateral empyema, 671 
Bile in newborn, 169 
Bile-ducts, congenital obstruction of, 
564 
enlargement of liver in, 
565 
of spleen in, 565 
etiology of, 564 
jaundice in, 564 
pathology of, 565 
symptoms of, 564 
Biliary pigment in urine, 31 
Bilirubin in meconium, 174 
Binaural stethoscope, 42 
Binder, body-, 61 
Birth, injuries during, 232 

loss of weight following, 24 
palsy, 232, 843 
paralysis, 232 
premature, 19 

sudden death iii, 10 
Blennorrhea of umbilicus, 207 

urogenital, 790 
Blindness, 40 

Blood, carbohydrates in, 85 
characteristics of, 739 
circulation o\\ 28 
diseases of, 73 I 
haemoglobin of. 736 



Blood in newborn, 168 

erythrocytes in, 169, 734 
histology of, 169 
leucocytes in, 169, 735 
polycythemia in, 734 
in rachitis, 245, 246, 735 
specific gravity of, 736 
Blood-cells, red, 734 

white, 735 
Boat-shaped abdomen, 44 
Bodies of Lourie, 89, 90 
Body, length of, 26 
in boys, 26 
in girls, 26 
increase, 26 
Body-binder, 61 

Body-temperature in newborn, 170 
Bone, changes of, in acute infectious 
osteomyelitis, 757 
in otitis, 760 
craniotabes of, 756 
diseases of, 755 

pains in, 755 
disturbances from sterilized milk, 

110, 111 
in rachitis, 755 
of skull, syphilis of, 756 
tuberculosis of, 756 
syphilis of, 756 

differentiation from tubercu- 
losis of bones, 755, 756 
tuberculosis of, 755 

differentiation from syphilis 
of bones, 755, 756 
Bone-marrow in leukaemia, 744 

in pseudoleukaemic anaemia, 740 
Botalli, duct of, 167 
Bothriocephalus latus, 558 
Bottle, nipples, care of, 62, 112 
nursing, 111 

care of, 111 
Freeman's, 111 
warming of, 112 
warmer, Sobel's, 112 
Bottle-fed children, increase of weight 
in, 25 
temperature in, 30 
urine in, 31, 32 
Bovinine, 115 
Bovril, 118 

"Bow-leg" deformity in rachitis. 244 
Bradycardia in hysteria, 805 
in lobar pneumonia, 021 
in myocarditis, 70S 
Brain, abscess of, diagnosis of. from 
convulsions in infancy, 800 
vomiting in, 50S 
basilar disease of, facial palsy and, 

853 
cortex of. tumors of, St 1 

symptoms of. S41 
cysts of. 840 
dropsy of. S33 
ganglia of. tumors of, 842 
symptoms of. 8 12 
grliomata of. s 10 



902 



INDEX. 



Brain, sarcomata of, 840 
tubercle of, 840 
tuberculosis of, 443 
tumor of, 840 

cerebrospinal fluid in, 76 
convulsions in, 841 
diagnosis of, from convul- 
sions in infancy, 800 
from epilepsy, 821 
etiology of, 840 
forms of, 840 
frequency of, 840 
headache in, 840 
location of, 840, 841, 842, 843 
nausea in, 841 
optic neuritis in, 841 
patellar reflex in, 49 
pulse in, 841 
respiration in, 841 
symptoms of, 840 
vomiting in, 508, 841 
vertigo in, 841 
Branchial cysts of oesophagus, 488 

fistulse of oesophagus, 488 
Brand bath, 65 

in typhoid fever, 333 
Brand's beef -extract, 118 
beef -juice, 115 
beef-peptone, 116 
Breast, abscess of, 128, 129 

infectious diarrhoea from, 129 
caking of, 129 

in newborn, 231 
treatment of, 129 
use of breast -pump in, 129 
care of, 127 
chicken-, 27 

colostrum in, appearance of, 127 
lymphangitis of, 129 
in newborn, 171 
milk in, 171 

biochemical theory of, 171 
composition of, 171 
nipples of, care of, 61 
nursing of infants at, 129 
placing of infants at, 128 
Breast-fed children, increase of weight 
in, 25 
temperature in, 30 
urine in, 31, 32 
Breast-feeding, colic in, 130, 131 
efficient, signs of, 130 
inefficient, signs of, 130 
stools in, variation of, 130, 131 
Breast-milk. See Milk, human 
Breathing, bronchial, 614 
bronchovesicular, 614 
normal, 613 
puerile, 613 
Breck's nursing tube, 189, 190 
Bright 's disease, contra-indication to 

maternal nursing, 124 
Bronchi, diseases of, 597 
Bronchial breathing, 614 

nodes in congenitally weak infants, 
184 



Bronchiectasis, 606 

bronchophony in, 609 
chest in, deformity of, 609 
complications of, 609 
congenital, 606 
cough in, 608 
course of, 609 
cysts in, 607 
diagnosis of, 609 
dyspnoea in, 608 
empyema and, 609 
etiology of, 607 
expectoration in, 608 
fever in, 608 
foreign bodies and, 607 
gangrene of lung and, 609, 610 
haemoptysis in, 609 
inflammatory, 607 
pathology of, 607 
physical signs of, 609 
pleurisy and, 607, 609 
pneumonia and, 607, 609 
symptoms of, 608 
syphilis and, 607 
treatment of, 610 
tuberculosis and, 609 
varieties of, 606 
Bronchitis, acute simple, 597 
age and, 597 
auscultation in, 599 
cough in, 598 
etiology of, 597 
exanthemata and, 597 
infectious diseases and, 

597 _ 
palpation in, 599 
pathology of, 598 
percussion in, 599 
physical signs of, 599 
rhachitis and, 597 
sputum in, 599 
symptoms of, 598 
syphilis and, 597 
treatment of, 600 
adenoid growths and, 582 
bronchopneumonia and, 635 
capillary, treatment of, 600 
chronic, 601 

in emphysema of lungs, 601 
in congenitally weak infants, 189 
fibrinous, 600 

asthma crystals in, 601 
casts in, 601 
complications of, 601 
cough in, 601 
cyanosis in, 601 
diagnosis of, 601 
diphtheria and, 600 
dvspncea in, 601 
etiology of, 600 
fever in, 601 

infectious diseases and, 600 
pathology of, 601 
physical signs of, 601 
pneumonia and, 600 
rales in, 601 






INDEX. 



903 



Bronchitis, fibrinous, splenic tumor in, 
601 
symptoms of, 601 
treatment of, 601 
tuberculosis and, 601 
in influenza, 342 
in measles, 302, 308, 309 
pertussis convulsiva and, 375 
plastic, 600 

putrid, 606. See also Bronchiectasis 
in sepsis in newborn, 201 
in typhoid fever, 328 
tuberculous, 601 
Bronchophony in bronchiectasis, 609 
bronchopneumonia and, 643 
in empyema, 662 
in pleurisy, 662 
Bronchopneumonia, 632 
age and, 632 
arthritis and, 642 
atelectasis in, 634 
bacteriology of, 633 
bronchitis and, 635 
bronchophony in, 643 
cerebral symptoms in, 638 
chronic, 648 
complications of, 640 
in congenitally weak infants, 184, 

185 
convulsions in, 634 
cough in, 634 
cyanosis in, 634. 635 
diagnosis of, 645 

from central pneumonia, 644 

from lobar pneumonia, 645 
diarrhceal conditions and, 640 
diphtheria and, 388, 640 
dyspnoea in, 634 
empyema and, 652 
equivocal signs of, 644 
etiology of, 633 
fever in, 635 

gangrene of lungs and, 640 
gastro-enteric tract in, 637 
hydrotherapy in, 646 
in influenza, 341 
measles and, 302, 308, 639 
meningitis and, 642 
occurrence of, 632 
onset of, 634 
osteomyelitis and, 642 
otitis and, 640, 759, 761 
pathology of, 633 
pericarditis and, 642 
pertussis convulsiva and, 375, 63S 
persistent, 648 

blood in, 649 

diagnosis of, 650 

physical signs of, 650 

symptoms of, 649 

treatment of, 650 
physical signs of, 642 
pneumococcus in, 033 
prognosis of, (> 15 
pulmonary tuberculosis and, 422 
pulse in, 636 
rales in, 643, 644 



Bronchopneumonia, scarlet fever and, 
639 

season and, 632 

sex and, 632 

sputum in, 637 

stages of, 642, 643 

surroundings and, 632 

symptoms of. 634 

treatment of, 646 

tuberculous, 421 

tympanites in, 637 

types of, 634 

typhoid fever and, 326, 639 

varicella and, 639 

vomiting in, 637 
Bronchovesicular breathing, 614 
Buhl 's disease, 221. See also Newborn, 

acute fatty degeneration of 
Burgoyne's beef -juice, 415 
Butter milk, 117 



Caking of breasts, 129 

in newborn, 231 
Calculi, biliary, 567 

renal, 775 
Calmette's tuberculin test, 424, 425 
Calories, 31 

in carbohydrates, 87 

in cows' milk, 86 

in fats, 87 

heat, 31 

in human milk, 86 

in proteids, 87 

required in artificially fed infants, 
88 
Cancrum oris, 483. See also Noma 
Cantani's salt-solution, 66 
Caput succedaneum, 26 

diagnosis of, from cephalohae- 
matoma, 235 
Carbohydrates, in blood, 85 

calories in, 87 

in cows' milk, 85 

in human milk, 85 

in liver, 85 

in lymph, 85 

in muscles, 85 

in nutrition, S5 
Carbon dioxide, excretion of, in respi- 
ration, 28 
Carbonic acid gas, excretion of, by in- 
fants, 88 
Carcinoma of kidney, 7S5 

of thymus gland, 729 
Cardiac area, 42 

disease, sudden death in. 20 

dyspnoea, 614 

hypertrophy in scarlet fever, 2S0 

insufficiency in chronic valvular 
disease of heart. 700 

murmurs, 704 
Caries of bono, facial palsy and. 852 
Carnrick 's peptonoids, .1 16 

soluble \'ooA. 120 
Casein, assimilation of. in cows' milk. 
103 



904 



INDEX. 



Casein, assimilation of, in human milk, 
103 
in cows' milk, 91, 102, 103 
in human milk, 81, 91, 92, 103 
Caseinogen in human milk, 91 
Casts in diabetes mellitus, 712 

in urine, 31 
Catalepsy, 814 

in hysteria, 803 
symptoms of, 814 
Cataract, congenital, nystagmus in, 4C 

corneal, nystagmus in, 40 
Catarrh, acute nasal, 574 

bacterial infection and, 

574 
diagnosis of, 575 
etiology of, 574 
infectious diseases and, 

574 
prognosis of, 575 
symptoms of, 575 
treatment of, 576 
chronic nasal, 576 

etiology of, 576 
lymphatism and, 576 
symptoms of, 577 
treatment of, 577 
enteric, 527 
Catarrhal appendicitis, acute, 548 
angina, 589 
croup, 593 
diphtheria, 384 

fever, acute, 339. See also Influenza 
icterus, 563 
influenza, 341 
laryngitis, 593 
otitis media, 759, 760 
pneumonia, 632 
tonsillitis, 589 
Caustic oesophagitis, 490 
Cephalohannatoma, 26, 234 
complications of, 235 
diagnosis of, 235 

from abscess of scalp, 235 
from caput succedaneum, 235 
from hernia of brain, 235 
from phlegmon of scalp, 235 
externa, 234 
interna, 234 
in newborn, 235 
pathogenesis of, 235 
prognosis of, 235 
symptoms of, 234 
treatment of, 236 
Cerebellum, tumors of, 843 
symptoms of, 843 
Cerebral abscess, otitis and, 760 
diplegia, 843 

disease, ataxic gait in, 50 
titubation, 50 
Cerebrospinal fever, 347. See Menin- 
gitis, cerebrospinal 
fluid, abnormal, 75 

specific gravity of, 75 
albumin in, 77 
bacteria in, 76 



Cerebrospinal fluid, blood in, 75 
in brain tumor, 76 
cytology of, 76 
in hydrocephalus, chronic,. 76 
lymphocytosis in, 76 
in meningitis, cerebrospinal, 
epidemic, 76 
sporadic, 76 
serosa, 368 
suppurative, 76 
tuberculous, 75 
normal, 74 
pressure of, 76, 77 
meningitis, 347 
Cerebrum in newborn, 175 
Cereo, in preparation of dextrinized 

gruel, 158, 159 
Cervical muscles, spasm of, position of 
head in, 40 
weakness of, position of head 
in, 40 
Chapin's method of artificial infant- 
feeding, 158 
Chapman 's whole flour, 121 
Charcot -Leyden crystals in amoebic 

dysentery, 534 
Chemise, 60 

Chemism of respiration, 28 
Chest, auscultation of, 613 
cardiac area of, 42 
circumference of . 27 
compress, cold, 65 
examination of, 40 

in infants, 40, 41 
in older children, 41 
position of patient in, 40 
fremitus in, 611 
inspection of, 42 
movements of, normal, 611 

restriction of, in effusion, 611 
in emphysema, 611 
in scoliosis, 611 
palpation of, 43 
percussion of, 43 
shape of, 27 

in rachitis, 27 
Chest-wall, resiliency of, 611 
Cheyne-Stokes respiration in septic en- 
docarditis, 698 
in tuberculous meningitis, 434, 
439 
Chicken-breast, 27 

Chickenpox, 310. See also Varicella 
Childhood, constitutional diseases in, 18 
definition of, 17 
infections in, 18 
intestinal disturbances in, 18 
morbidity in, 17 
respiratory disturbances in, 18 
Chill in onset of illness, 37 
Chlorosis, 738 

blood in, 738 
etiology of, 738 
Cholecystitis in typhoid fever, 333 
Cholera asiatica from infected cows' 
milk, 105 



INDEX. 



90S 



Cholera infantum, 521. See also Gas- 
troenteric infection, acute 

diagnosis of, 523 

from infectious diseases, 
523 

hypodermoclysis in, 66 

prognosis of, 522 

symptoms of, 521 

treatment of, 523 
Chondrin, 84 

Chondrodystrophia foetalis, 250 
diagnosis of, 251 

from osteogenesis imper- 
fecta, 252 

long bones in, 250 

pathology of, 250 

prognosis of, 252 

skull in, 250 

symptoms of, 251 
hyperplastica, 250 
hypoplastica, 250 
Chondrogen, 82 
Chondromalacia foetalis, 250 
Chorea, 822 

in acute articular rheumatism, 462 
age and, 823 
arthritic pains in, 825 
cardiac murmurs in, 827 

symptoms in, 826 
diagnosis of, 828 

from athetoid movements, 828 

from chorea insaniens, 831 

from habit movements, 828 

from tic convulsif, 828 
electric reactions in, 825 
electrica, 822 

endocarditis and, 690, 693, 826 
epidemic, 823 
epilepsy and, 825 
etiology of, 823 
frequency of, 823 
fright and, 823 
habit movements in, 828 
Huntington's, 823 
infectious diseases and, 824 
insaniens, 822, 829 

delirium in, 830 

diagnosis of, from simple 
chorea, 831 

fever in, 830 

symptoms of, 830 

sex and, 829 

treatment of, 831 
laryngeal, 822 
lymphatism and, 823 
major, 822 

mental symptoms in, S28 
minor, 822 

multiple neuritis and, 825 
muscular twitchings in, 825 
night -terrors in, 825 
onset of, 82 I 
pat hology of, 824 
pericardii is in, 826 
post-hemiplegic, in infantile cere- 
bral palsy, SIS 



Chorea, prognosis of, 828 

refractive errors and, 823 

rheumatism and, 823, 824 

scarlet fever and, 281 

sex and, 823 

speech in, 826 

Sydenham's, 822 

symptomatic, 822 

symptoms of, 824 

temperature in, 827 

tongue in, 825 

trauma and, 823 

treatment of, 829 

urine in, 826 

wrist-drop in, 825 
Chvostek's symptom in status lymphat- 
icus, 730 
in tetany, 811 

in tuberculous meningitis, 435 
Chylous ascites, 568 

Clubbed fingers in stenosis of pulmon- 
ary artery, 688 
Clothing, 60 

of congenitally weak infants, 190 
Circulation in newborn, 167 
Circulatory disturbances, sudden death 
in, 20 

system, diseases of, 674 
Cirrhosis of liver, 565 
Cocoa, acorn, 119 

Coffee, effect of, on human milk, 97 
Cold chest compress, 65 

pack, 65 

sense in newborn, 177 
Colic, 508 

in acute gastro-enteric infection, 
521, 526 

in bottle-fed infants, 152. 153 

in breast-feeding, 130, 131 

cause of, 508 

colostrum corpuscles and, 130, 131 

symptoms of, 508 

tenseness of abdomen in, 44 

treatment of, 509 

tympanites and, 508 
Colicystitis, 193. See also Cystitis. 
Colitis, amoebic, 534 

contagiosa, 528 
Colles's law in hereditarv syphilis, 44S 
Collogen, 82 

Colon, congenital dilatation of. 540 
prognosis of, 540 
symptoms of, 541 
treatment of. 542 
Colostrum, S9 

appearance of, in breast. 127 

color of, SO 

coloring-matter of. 00 

composition of. ^9 

corpuscles. SO. 00 

colic ami. 130, 133 

crescents ot\ $9. 00 

decomposition of, on nipples. 128 

disappearance o\'. 00 

Lourie's bodies in. SO. 00 

microscopic appearance of, SO. 90 



906 



INDEX. 



Colostrum, physical properties of, 89 
specific gravity of, 89 
time of appearance of, 89 
Condensed milk, 113 
Congenital ansemia, 736 
bronchiectasis, 606 
constipation, 535 
dilatation of colon, 510 
hydrocele, 182 
ichthyosis, 893 
internal hydrocephalus, 833 
pyloric spasm, 511 
rachitis, 237 
stridor of infants, 815 
syphilis, 448 
tuberculosis, 419 
Congenitally weak infants, 183 
Conjunctival tuberculin test, 425 
Conjunctivitis blennorrhoeica, 228 
in measles, 295, 304 
in scarlet fever, 276 
vulvovaginitis and, 792 
Conrad's lactobutyrometer, 100 

lactodensimeter, 100 
Consanguinity, pseudohypertrophic mus- 
cular paralysis and, 873 
Constipation, 535 
acquired, 536 
acute, 536 

diagnosis of, 536 
foreign bodies and, 536 
intussusception and, 536 
peritonitis and, 536 
strangulation and, 536 
chronic, 536 

anal fissure and, 537 
new growths and, 537 
in acute nephritis, 780 

peritonitis, 569 
in artificial infant-feeding, 152 
congenital, 535 

absence of anus and, 535 
malformations and, 535 
in fissure of anus, 553 
from frozen milk, 111 
habitual, chronic, 537 

anaemia in, 539 
diet in, 539 
enemata in, 540 
etiology of, 537 
habits in, 540 
heredity and, 538 
incorrect feeding and, 538 
massage in, 540 
predisposition toward, 537 
rachitis and, 537 
stools in, 538 
symptoms of, 538 
treatment of, 539 
in pyloric spasm, 513 
from sterilized milk, 108 
Constitutional diseases, 711 

in childhood, 18 
Contractures in infantile cerebral palsy, 

846 
Convulsions in infancv, 797 



Convulsions in infancy, alcohol and, 
798, 799 
coma in, 800 
diagnosis of, 800 

from abscess of brain, 800 
from meningitis, 800 
from tetany, 801 
from tumor of brain, 800 
duration of, 800 
etiology of, 797 
gastro-enteric disease and, 798 
heredity and, 798 
pathology of, 799 
prognosis of, 801 
symptoms of, 799 
treatment of, 801 
in infantile cerebral palsy, 845 
in scarlet fever, 279 
in tumor of brain, 841 
Convulsive forms of hysteria, 803 
Coomb's malted food, 121 
Coprolalia in tic, 832 
Cord, umbilical, 52. See Umbilical cord 
Corneal ulcerations in measles, 304 
Corpuscles, colostrum, 89, 90 
Coryza in measles, 294, 295, 296 
Cows' milk. See Milk, cows' 
Cranial bones in congenital internal hy- 
drocephalus, 834 
Cranioschisis, 880 

Craniotabes in congenital internal hy- 
drocephalus, 834 
laryngismus stridulus and, 817 
in rachitis, 237, 240, 245 
shape of head and, 38 
Crawling, development of, 35 
Crede method, 56 

in ophthalmia neonatorum, 229 
Crepitations, pleuritic, in empyema, 660 
Crepitus of joints, 46, 47- 
Crescents of Lourie, 89, 90 
Crescent-shaped bodies in human milk, 

93 
Cretinic form of idiocy, 878 
Cretinism, 718 
endemic, 718 

goitre in, 718 
skull in, 718 
sporadic, 719 

age and, 719 
blood in, 721 
bones in, 724 
diagnosis of, 724 

from dwarfism with idiocy, 

725 
from infantilism, 725 
from Mongolian idiocy, 

724 
from rachitis, 246 
etiology of, 722 
facial expression in, 720, 721 
genitals in, 721 
hands in, 722 
macroglossia in, 722 
mental dulness in, 720, 722 
pathology of, 723 



INDEX. 



007 



Cretinism, sporadic, skin in, 720, 722 
symptoms" of, 719 
tongue in, 722 
treatment of, 725 

thyroid extract in, 725 
Croup, catarrhal, 593 

spasmodic, 593 
Croupous pneumonia, 615 
Crus cerebri, tumors of, 842 
Cryptorchism, 182 
Curvature of spine, 47 
Cutaneous scarification tuberculin test, 

425 
Cutis sebacea, 893 
Cyanosis in bronchopneumonia, 634, 635 

in congenital heart disease, 685 

in fibrinous bronchitis, 601 

in onset of illness, 37 
Cyclic albuminuria, 770 

vomiting-, 503 
Cystitis, 793 

anaemia in, 795 

Bacillus coli communis in, 793 

diagnosis of, 795 

diphtheria and, 793 

etiology of, 793 

fever in, 794 

frequency of, 794 

influenza and, 793 

intestinal disturbance and, 793 

measles and, 793 

pain in, 795 

pneumonia and, 793 

scarlet fever and, 793 

symptoms of, 794 

treatment of, 796 

urine in, 795 
Cysts in bronchiectasis, 606 

of kidney, 784 



Dactylitis syphilitica, 455 

Dancing mania in hysteria, 804 

Darby's fluid meat, 116 

Davidson's shield for fissured nipples, 

128 
Deafness in newborn, 176 

in scarlet fever, 275 
Death, sudden, 19 

in anaesthesia, 22 

in aneurysm, 20 

from atelectasis, 19 

in bronchopneumonia, 20 

in cardiac disease, 20 

in cerebral abscess, 21 

in circulatory disturbances, 20 

in disease of central nervous 

system, 21 
hyperthermia and, 21 
intoxications and, 21 
in lumbar puncture, 22 
lymphatism and, 22 
in newborn, 179 

apoplexy and, 180 
hemorrhage and, 180 



Death, sudden, in newborn, prodromes 
of, 180 
in premature birth, 19 
in respiratory disease, 20 
in retropharyngeal abscess, 20 
in tetany, 22 
Dejerine type of facio-scapulo-humeral 

muscular atrophy, 873 
Dengeyer's peptone, 116 
Dentition, abnormal, 471 
dental erosions in, 472 
incisions of gums in, 474 
normal, 470 
pathology of, 474 
in rachitis, 471 
in syphilis, 471 
Dermatitis exfoliativa, 892 
course of, 893 
etiology of, 892 
prognosis of, 893 
in sepsis in newborn, 201 
symptoms of, 892 
treatment of, 893 
Desquamation in newborn, 17, 170 

in scarlet fever, 273 
Development, mental, 34, 35, 36 

physical, 34, 35, 36 
Dew method of artificial respiration, 196 
Dextrinized barley, 158 
gruel, 158 

in artificial infant-feeding, 158 
Dextrose in urine, 34 
Diabetes insipidus, 712 

symptoms of, 712 
urinary, 713 
treatment of, 714 
mellitus, 711 

acetone breath in, 712 
casts in, 712 
diagnosis of, 712 
etiology of, 711 
furuncles in, 712 
polydipsia in, 712 
pruritus in, 712 
skin in, 712 
symptoms of, 711 
treatment of, 712 
Diacetic acid in urine, 33 
Diapers, 57 

change of, 57 
material for, 57 
washing of, 57 
Diaphragmatic respiration. 28 
Diarrhoea in acute gastro-enteric infec- 
tion, 520, 524 
in congenitallv weak infants. 185 
fat, S4, 153 
facial expression in. 39 
from frozen milk. 111 
in influenza. 341 
in measles, 303 
from raw milk. 110 
in scarlet fever. 2S0 
in sepsis in newborn. 201. 205 
summer. 5 1 7 
Diastase in artificial infant foods. 119 



908 



IXDEX. 



Diastase in preparation of dextrinized 

gruel, 158 
Diastased farina. 121 
Diatheses, hemorrhagic. 747 

transmission of, by wet-nursing, 
122, 123 
Diazo reaction, Ehrlich's. in typhoid 

fever, 331 
Dicrotism, 30 

Diet after operations, 164 
articles of, to avoid, 162 
during convalescence, 164 
infantile scorbutus and, 255 
in rachitis, 247 
in sick infants. 164 
Dietaries for infants and children, 162, 

163 
Diffuse nephritis, acute, 776, 777 

chronic, 781 
Digestive functions in newborn, 169 
Dilatation of heart, 709 

of stomach, 509 
Diphtheria, 378 
age and, 378 
antitoxin in, 397 
dosage of, 397 
effect of, 398 

on blood, 399 
on kidneys, 399 
on temperature, 399 
eruptions after. 399 
injection of, method of, 398 
bacillus of, 379 
blood in, 384 

bronchopneumonia and, 388, 640 
catarrhal, 384 
complications of, 388 
contagion of, 379 
course of, 388 
diagnosis of, 394 

from aphtha?, 395 

from catarrhal laryngitis, 593 

from diphtheroid, 394 

from herpes of fauces, 395 

from laryngismus stridulus, 

394 
from stomatitis, 394 
from traumatic sorethroat, 396 
disinfection in, 396 
duration of, 388 
endocarditis and, 690 
erythema urticatum in, 393 
etiology of, 379 
exanthema of, 393 
false, 410. See also Diphtheroid 
fibrinous bronchitis and, 600 
forms of, 384 
gastro-enteritis and, 389 
heart in, 382 
human milk and, 97, 98 
incubation of, 379 
from infected cows' milk, 105 
infection in, 380 
intubation in, 402 
dangers of, 408 
extubation in, 408 



Diphtheria, intubation in, feeding in, 409 

indications for, 402 

instruments for, 402 

method of, 402 

O'Dwyer's tubes in, 402 
kidneys in, 383 
laryngeal, 387 

treatment of, 401 
liver in, 383 
localized forms of, 384 
lungs in, 382 
lymph-nodes in, 383, 385 
measles and, 301, 309, 396 
melancholia in, 392 
membrane of, 382, 394 
middle ear in, 383 
muscular atrophy in, 49 
myocarditis and, 707 
of nasal passages, 393 
nephritis and, 389 
nerves in, 383 
occurrence of, 378 
ophthalmia and, 392 
paralysis and, 391 

cardiac, 390 

of soft palate in, 395 

treatment of, 409 
pathology of, 381 
pertussis convulsiva and, 393 
pleuritis and, 388 
prognosis of, 396 
prophylaxis of, 396 
pseudobacillus of, 380 
retropharyngeal abscess and, 389 
in scarlet fever, 270 
sensory nerves in, 392 
septic, 385 
sex and, 379 
sine membrana, 384 
of skin, 392 
spleen in, 383 
stomach in, 383 
symptoms of, 384 
thymus gland and, 729 
toxins of, 380 
treatment of, 396 

constitutional, 397 

local, 401 
in typhoid fever, 328 
ulcers of, diagnosis of, from ulcero- 
membranous tonsillitis, 592 
of vulva, 392 

treatment of, 409 
Diphtheritic ophthalmia, 392 
paralysis, 391 

cardiac, 390 
rhinitis, 578 
Diphtheroid, 410 

diagnosis of, 410 

from diphtheria, 394 
etiology of, 410 
in scarlet fever, 270 
symptoms of, 410 
treatment of, 411 
Diplegia, 843 

cerebral, 843 



INDEX. 



909 



Diplocoecus intracellularis in cerebro- 
spinal meningitis, 347 
pneumonias in cerebrospinal menin- 
gitis, 348 
Dirt-eating, 805 
Diverticula of oesophagus, 488 
Dropsy of brain, 833 
Drugs, administration of, 63 
antipyretic, 63, 64 
cautions concerning, 62, 63 
dosage of, 64 

eruptions of, diagnosis of, from 
measles, 307 
from scarlet fever, 282 
in human milk, 97 
Dry pleurisy, 650 
Ductus arteriosus, closure of, 167 

in congenitally weak infants, 

184 
open, 686, 687, 689 
murmur in, 689 
physical signs of, 689 
right ventricle in, 689 
Botalli. See Ductus arteriosus 
disease, 689 
Dulness, normal, in percussion, 612 
Dusting-powder, 61 
Dwarfism, 726 

differentiation of, from infantil- 
ism, 726 
with idiocy, diagnosis of, from 
sporadic cretinism, 725 
Dwarfs, 727 

Dyscrasias, constitutional, melaena neo- 
natorum in, 220 
Dysentery, 528 

acute nephritis and, 778 
amoebic, 534 

Charcot-Leyden crystals in, 534 
diagnosis of, 534 
etiology of, 534 
treatment of, 535 
arthritis in, 532 
bacteriology of, 529 
complications of, 532 
diagnosis of, from intussusception, 

545 
diet in, 533 

enemata in, rectal, 533 
etiology of, 529 
forms of, 529 

from infected cows' milk, 105 
intestinal perforation in, 532 
pathology of, 530 
periproctitic abscess in, 532 
peritonitis in, 532 
prognosis of, 532 
prophylaxis of, 532 
serum for, 534 
symptoms of, 530 

Treatment of, 532 

Dyspepsia, acute gastric, 502 

symptoms of, 502 

treatment o\\ 502 

infant foods in, use of, L57 
Dyspnoea in abdominal tumors. 615 



Dyspnoea in ascites, 615 

in asthma, 614 

in atelectasis, 199 

in bronchiectasis, 609 

in bronchopneumonia, 634 

cardiac, 614 

in chronic valvular disease of heart, 
703 

in dilatation of heart, 709 

in emphysema of lungs, 604, 605 

in fever, 614 

in fibrinous bronchitis, 601 

forms of, 614 

laryngeal, 614 

in lobar pneumonia, 618, 622 

in myocarditis, 708 

in pain, 614 

in pericarditis, 676 

pulmonary, 614 
Dysuria, 773 

cellular atresia of labia and, 773 

treatment of, 773 



Ear, diseases of, 759 

examination of, 762 
Echolalia in tic, 832 
Echymoses in infantile scorbutus, 257 
Eclampsia, acetone in urine in, 33 
infantum, 797 
in scarlet fever, 279 
Ecthyma in scrofulosis, 413 
Ectopia testis abdominalis, 181 
cruralis, 182 
perinealis, 182 
Eczema, 884 

etiology of, 886 
forms of, 885 
impetiginous, 885 
intertrigo, 885 

pustular, 885 
in scrofulosis, 413 
seborrhoeic, 886 
treatment of, 887 
vaccination and, 317 
vesicular, 885 
Effusion, restriction of movements of 

chest in, 611 
Ehrlich diazo reaction in typhoid fever, 

331 
Elastin, 84 
Electric chorea, S22 

stimulation and reactions in new- 
born, 175 
Emphysema of lungs, 601 
adenoids in, 602 
asthma in. 604 
auscultation in. 603. \S0o 
chest in. deformity of. 602. 604 
chronic bronchitis in. 601. 602 
dyspnoea in. 604. 605 

spasmodic. 604 
enlarged tonsils in. 602 
inspection in. 60 1 
lymphatism and. 602 



910 



INDEX. 



Emphysema of lungs, palpation in, 603, 
605 

pathology of, 602 

percussion in, 603, 605 

physical signs of, 603 

prognosis of, 606 

rachitis and, 602 

restriction of movements of 
chest in, 611 

symptoms of, 602 

thorax in, 602 

treatment of. 606 

vesicular, 602 
Empyema, 650, 652 
adhesions in, 671 
age and, 652 
appendicitis and, 652 
aspirator for, Potain's, 667 
auscultation in, 658, 661 
bacteriology of, 653, 654 
bilateral, 671 

prognosis of. 672 

treatment of, 672 
bronchiectasis and, 609 
bronchophony in, 662 
bronchopneumonia and, 652 
diagnosis of, 657 

fluid in, 662 
etiology of, 652 
exploratory puncture in, 663 
exudate in, 653 
heart in, displacement of, 662 
hemorrhagic, 672 
infectious diseases and, 652 
inspection in. 658, 659, 660 
liver in, displacement of, 662 
lobar pneumonia and, 627, 628, 652 
metapneumonic, 657 
onset of, 656 

palpation in, 658, 659, 660 
pathology of, 653 
percussion in, 658, 659, 660 
perforating, 664 
physical signs of, 657 
pleural fold in, displacement of, 

661 
pleuritic crepitations in, 660 
primary, 652 

puncture in, exploratory, 663 
in scarlet fever, 276 
secondary, 652 

simulating enlargement of liver, 562 
skodaic resonance in, 659 
suppurating sinus in persistent, 670 
symptoms of, 656 
temperature in, 656 
termination of, 665 
treatment of, 666, 667, 668, 669 

operative, 669, 670 
tuberculous, 666 
viscera in, displacement of, 662 
Encephalitis, acute, 859 

aphasia in, 860 

etiology of, 859 

hemorrhagic cortical, 859 

Kernig's symptom in, 860 



Encephalitis, acute, lumbar puncture 
in, 861 

meningitis and, 860 

neck-rigidity in, 860 
. paralysis in, 860, 861 

pathology of, 859, 860 

prognosis of, 861 

symptoms of, 860 

tache cerebrale in, 860 

treatment of, 861 
Encephalocele, 880 
Endocarditis, 690 
acute, 690 
acute articular rheumatism and, 

461, 690 
auscultation in, 694 
bacterial invasion in, 692 
bacteriology of, 690 
cerebrospinal meningitis and, 690 
chorea and, 690, 693, 826 
diphtheria and, 690 
in erythema multiforme, 891 

nodosum and, 690 
etiology of, 690 
fever in, 692 

in follicular amygdalitis, 590 
gonococcus in, 691 
heart-action in, 695 
influenza and, 341, 690 
inspection in, 694 
location of, 690 
malignant, 696 
measles and, 303, 690 
modes of infection in, 691 
murmurs in, 694 
osteomyelitis and, 690 
palpation in, 694 
pathology of, 691 
percussion in, 694 
pericarditis and, 692 
physical signs of, 694 
pneumonia and, 690 
polyp osa, 691 
prognosis of, 695 
pustulosa, 692 
recurrent, 694 

chronic, 699 
rheumatism and, 693 
scarlet fever and, 279, 690 
sepsis and, 690 
septic, 696 

blood in, 698 

Cheyne-Stokes respiration in, 
698 

diagnosis of, 699 

dilatation of ventricle in. 698 

forms of, 696 

murmurs in, 698 

petechia? in, 698 

prognosis of, 699 

symptoms of, 698 

treatment of, 699 
symptoms of, 692 
temperature in, 693 
tonsillitis and, 466 
tonsils in, infection through, 691 



INDEX. 



fill 



Endocarditis, toxins in, 691 
treatment of, 695 
tuberculosis and, 690 
typhoid fever and, 690 
ulcerosa, 692 
ulcerative, 696 
valvular vegetations in, 692 
verrucosa, 691 
Endemic cretinism, 718 
Enemata in nephritis, 73 
nutritive, 74 
oil, 74 

in pyloric spasm, 517 
rectal, 72 

in acute gastro-enteric infec- 
tion, 525 
in dysentery, 533 
in typhoid fever, 73 
in vomiting, uncontrollable, 74 
Enlargement of spleen, 733 
Enteratomata of umbilicus, 207 
Enteric catarrh, 527 

Enteritis, diagnosis of, from typhoid 
fever, 330 
follicularis, 527, 528 
Enteroclysis, 72 
Enterocolitis, 527 
etiology, 527 
pathology of, 527 
symptoms of, 528 
treatment of, 528 
Enuresis diurna, 789 
nocturna, 789 

diagnosis of, 789 
etiology, 789 
symptoms of, 789 
treatment of, 789 
Enzymes in human milk, 88, 89, 94 
Epidemic cerebrospinal meningitis, 348 
chorea, 822 
hysteria, 804 

parotitis, 368. See also Mumps 
poliomyelitis, 861 
Epididymis, metastasis of mumps ' to, 

371 
Epilepsy, 819 
aura in, 820 
chorea and, 825 
convulsions in, 820 
diagnosis of, 821 

from hysteria, 821 
from post-hemiplegic convul- 
sions, 821 
from syncope, 821 
from tumor of brain, 821 
etiology of, 820 
forms of, 820 
heredity and, 820 

in infantile cerebral palsy, 845, 849 
infantile palsy and, 820 
pavor nocturnus and, 822 
symptoms of, 820 
treatment of, 821 
Epileptic form of idiocy, S78 
Kpistaxis, 579 

loss of blood in, quantity o\\ 579 



Epistaxis, symptoms of, 579 
Epithelium, exfoliated, in otitis, 764 
Epstein's pearls, 203 
Erb 's palsy, 857 

type of progressive muscular atro- 
phy, 872 
Eruption in scarlet fever, 271 
Erysipelas of umbilicus, 209 
Erythema exudativum, 890 

cardiac disease in, 891 
intertrigo, 885 
multiforme, 890 

endocarditis in, 891 
treatment of, 891 
nodosum, 466, 890 

endocarditis and, 690, 691 
symptoms of, 890 
treatment of, 891 
Erythrocytes, 734 

in newborn, 169 
Escherich's method of artificial infant- 
feeding, 135 
Eskay's food, 121 
Essential paralysis of children, 861 
Exanthemata, 265 

Exanthematic fevers, acetone in urine 
in, 33 
diacetic acid in urine in, 31 
Excitement, rapidity of pulse during, 30 
Excreta, calculation of calories from, 87 
Excretion in newborn, 177 
External cephalhematoma, 234 

hydrocephalus, 836 
Exudative nephritis, acute, 776, 777 
Eye reflexes in newborn, 176 
Eyes in newborn, 55 

cleansing of, 55, 56 



Face, expression of, in adenitis, 39 

in adenoids, 39 

in Basedow's disease, 39 

in cardiac disease, 39 

in congenital syphilis, 40 

in diarrhoea, 39 

in exhausting diseases, 39 

in facial paralysis, 39 

hydrencephaloid, 40 

in hydrocephalus, 39 

in Mongolian idiocy, 40 

in mouth-breathing. 39 

in nuclear palsy, 39 

in parotiditis, 39 

in rachitis, 39 

in respiratory disorders. 39 

in sleep, norma 1, 39 
protection of, in open air. 60 

against sun 's rays. 60 
Facial palsy, 851 

Facio-scapulo-humeral type of muscu- 
lar atrophy, 873 
Fseces, examination 01'. 38 
Kaii-child's panopeptone. 116 
family idiocy. S3 7 
Fat, in artificial infant foods. 121 



912 



IXDEX. 



Fat iu infant-feeding, 137 
calories in. 87 
in cows' milk, 102, 103 
diarrhoea. 81 

in artificial infant -feeding. 153 
digestion of. in newborn, 169 
estimation of. in human milk. 100 
Lewi's method of, 100. 101 
Soxhlet 's quantitative, 101 
in human milk. 93 
percentage of, in cows' milk, 81 
in human milk, 81 
low. 151 
role of, in nutrition, 81 
Fat-sclerema, 226 
Fatty acids in human milk, 93 

degeneration, acute, of newborn, 
221 
of liver. 565 

true omphalorrhagia in, 212 
Feeding, artificial, of congenitally weak 
infants, 191 
mortality and, 18 
breast, of congenitallv weak in- 
fants. 190 
infant-. SI 

of infants. See Infant-feeding 
mixed, of congenitallv weak in- 
fants. 192 
Ferments, amylolytic. in newborn, 169 

in human milk. 91 
Fever, ataxic gait after, 50 
cardiac murmurs in. 705 
in onset of illness. 37 
sponge bath in, 65 
typhoid. 318 
Fibrinous bronchitis. 600 
pericarditis, 671 
pneumonia. 615 
Filth infections, 18 
Finger-nails, biting of, 806 
Fissure of anus. 553 

palpebral, examination of. 10 
Fissured nipples, 128 
Flexner's serum in cerebrospinal men- 
ingitis, 360 
in posterior basic meningitis. 
366 
Floating kidney. 45. 770 
Fluid, cerebrospinal. See Cerebrospinal 
fluid 
free, in abdomen. 11 
Fcetal rachitis. 237 
rickets, 250 
tuberculous, 119 
typhoid fever, 319 
Follicular amygdalitis, 589 
Folliculitis abscedens, 891 
Fontanelles, 26, 27 

closure of, time of, 27 

delay of, in rachitis. 27 
premature closure of, in micro- 
cephalia, 38 
Food, effect of, on human milk, 96 

infant, use of, indications for, 157 
preparations, 112 



Foot, deformities of, in spina bifida, 

881 
Foramen ovale, open, 689 
Foreign bodies in larynx. 597 
Fragilitas ossium idiopathica. 252 
Freeman's nursing bottle. Ill 

pasteurizer. 106. 107 
Fremitus in chest, 611 
Friedreich's disease, 858. See Ataxia, 

hereditary 
Frontal lobe, tumors of. S41 
Frozen milk, 111 
Fungus of umbilical cord, 53 

of umbilicus, 207 
Funnel. Quincke, 81 
Furuncles in diabetes mellitus. 712 
Furunculosis, 891 

symptoms of, 891 

treatment of. 891 

G 

Gait, ataxic, 50 

in cerebral disease, 50 

tumor, 50 
in diphtheritic paralysis. 50 
in Friedreich's ataxia, 50 
after fevers, 50 
in pseudohypertrophic paral- 
ysis. 50 
limping. 51 

in infantile paralysis, 51 
in pseudohypertrophic muscular 

paralysis. S71 
spastic, 51 

in spastic paraplegia, 51 
in young infants, 51 
Gallop-rhythm in myocarditis, 708 
Gangrene of the lungs in bronchiecta- 
sis, 609, 610 
in scarlet fever, 280 
in typhoid fever. 328 
of pinna in measles, 305 
in scarlet fever, 272 
of umbilical cord, 53 
of umbilicus, 208 
Gangrenous acute appendicitis, 519 
Gastric dyspepsia, acute, 502 

spasm, congenital, 512 
G astro-enteric disturbances, barley wa- 
ter in, 111 
infection, acute. 517 

albuminuria in, 520 
bacteriology of, 518, 519 
baths in, 525 
classification of. 518 
colic in, 521, 526 
diarrhoea in, 520, 521 
diet in, 524 
etiology of, 518 
hypodermoelysis in, 525 
intestines in. 519 
kidneys in, 519 
liver in, 519 
lymph-nodes in, 519 
pathology of, 519 



INDEX. 



Gastroenteric infection, acute, prog- 
nosis in, 521 
prophylaxis of, 523 
rectal enemata in, 525 • 
stomach in, 519 
symptoms of, 520 
treatment of, 523 

medicinal, 526 
vomiting in, 520, 524 
G astro-enteritis, 517. See also Gastro- 
enteric infection, acute 
acute nephritis and, 778 
administration of water in, 83 
condensed milk in, 113, 114 
diphtheria and, 389 
indican in urine in, 33 
in pertussis convulsiva, 376 
tympanitis in, 45 
Gastro-intestinal tract, diseases of, 493 
Gavage, 71, 72 

in congenitally weak infants, 189 
in pneumonia, 71 
in typhoid fever, 71 
Genitalia, care of, 57, 58 
in females, 58 
in males, 58 
powdering of, 58 
Genetous idiocy, 877 
Geographical tongue, 486 
German measles, 291. See Eotheln 
Glandular fever, 345 

diagnosis of, 346 
duration of, 346 
etiology of, 345 
lymph-nodes in, 345 
symptoms of, 345 
treatment of, 346 
Globus hystericus in hysteria, 803 
Glomerular nephritis, 776 
Glottis, oedema of, 594 

spasm of, 816 
Glutin, 84 
Glycogen, 85 

Goitre in endemic cretinism, 718 
Gonococcal peritonitis, 570 
Gonococci in vulvovaginitis, 791 
Gonorrhceal infection of mouth, 482 
ophthalmia, 55, 56, 228 
proctitis, 554 
rheumatism, 466 
Grand mal, 820 
Granuloma of umbilicus, 207 
Grape sugar, 85 

Grippe, 399. See also Influenza 
Growths, adenoid, 579 
Gruel, arrowroot, 115 
barley, 157 
dextrinized, 158 

preparation of, 158, 159 
cereo in, 158, 159 
diastase in, 158 
oatmeal, 115 

H 

Habits, bad, 805 
movements, S31 
58 



Habits in chorea, 828 

diagnosis of, from chorea, 328 
spasms, 831 
Habitual vomiting of infants, 503 
Hematoma of sternomastoid muscle, 233 
symptoms of, 233 
treatment of, 234 
Hematuria, 774 

in carcinoma of kidney, 786 
etiology of, 774 
in infantile scorbutus, 256, 257 
in sarcoma of kidney, 785 
urine in, 774 
Haemoglobin, 736 
Haemoglobinuria, 774 

epidemic, of newborn, 222. See 

Winekel's disease 
etiology of, 774 
pathology of, 775 
prognosis of, 775 
"shadow'' cells in, 775 
symptoms of, 775 
treatment of, 775 
Haemophilia, 219, 748 
etiology of, 748 
hemorrhages in, 749 
nature of, 748 

in newborn, hemorrhages in, 219 
treatment of, 749 
Haemoptysis in bronchiectasis, 609 

in pulmonary tuberculosis, 423 
Hallucinations in pavor nocturnus, 822 
Head, circumference of, 26 
examination of, 38 
lymph-nodes of, 33 
measurements of, 26 
position of, in amaurotic idiocy, 35, 
38 
in birth-paralysis, 38 
in defective vision, 40 
in diphtheritic paralysis, 38 
in meningitis, 38 
in Pott's disease, 38 
in spasm of cervical muscles, 

40 
in torticollis, 38 
in weakness of cervical mus- 
cles, 40 
power to hold upright, develop- 
ment of, 35 
rhythmic movements of, nvstagmus 
and. S32 
dentition and, 832 
etiology of. S3 '2 
rachitis and. 832 
treatment o\. - 
rolling of. from side to side. S06 
shape of. in craniotabes, 38 
in rachitis, 38, 240 
Head-banging. 806 
Head-nodding, 806, 832 
Head-swaying. 806 
Hearing, development of, 35 

sense Of, in newborn. 176 
Heart, apex-beat of, 682 
ausoultatioo in. 683 



914 



IXDEX. 



Heart, congenital disease of. 685 

cardiac dilatation in, 685 
hypertrophy in, 685 
cyanosis in, 685 
diagnosis of, 686 
murmurs in, 686 
open ductus arteriosus in, 

686, 687 
pulmonary artery in, 636 
septal defects in, 686 
stenosis of aortic yalye in, 

686 
transposition of heart in, 

687 
yalvular anomalies in, 687 
ventricular hypertrophy 
in, 686 
dilatation of,' 709 

in congenital disease of heart, 

685 
dyspnoea in, 709 
infectious diseases and, 709 
sudden death in. 709 
symptoms of. 709 
transudates in, 709 
treatment of, 710 
disease of, 682 

contra-indication to maternal 

nursing, 124 
in erythema exudativum, 890 
nodosum, 891 
displacement of, in empyema, 662 
dulness in, marking of, 683 
hypertrophy of, 709 

arteriosclerosis and, 709 

in congenital diseases of heart, 

685 
symptoms of, 709 
treatment of. 710 
inspection of, 682 
irritable, 700, 701 
palpation of, 683 
percussion in, 683 
position of, 682 
praecordium of, 682 
size of, 682 
transposition of, 687 
tuberculosis of, 432 
valvular disease of, chronic, 699 
angina in, 703 
cardiac insufficiency 

in, 700 
dyspnoea in. 703 
etiology of, 699 
myocarditis and, 708 
pallor in. 701 
palpitation in, 701 
physical signs of, 700 
prognosis of, 703 
treatment of, 703 
rheumatic pains in, 
700 
ventricles of, location of, 684 
Heat calories, 31 

sense in newborn, 177 



Hemiplegia in infantile cerebral palsy, 
846 
spastic, 843, 845. See also Palsy, 
cerebral, infantile 
Hemorrhage in acute fatty degenera- 
tion of newborn, 222 
cerebral, diagnosis of, from as- 
phyxia in newborn, 195 
in newborn. 219 
in Buhl's disease, 219, 222 
in sepsis, 219 
in haemophilia, 219 
syphilitic, 219 

in Winekel's disease, 219, 223 
sudden death in newborn and, 180 
Hemorrhagic conditions in sepsis in 
newborn, 201 
cortical encephalitis, acute, 859 
diatheses, 747 
empyema, 672 
periostitis, 254 
pleurisy, 672 
rachitis, 237, 254 
Hennig's symptom, 210 
Henoch's purpura. 752 
Hepatitis, suppurative, 566 
Hepatization in lobar pneumonia. 616 
Hereditary syphilis, 448 
ataxia, 858 

ataxic paraplegia, 858 
Hernia of brain, diagnosis of, from 
cephalohsematoina, 235 
diagnosis of, from hydrocele con- 
genita, 183 
from retention of testicle, 182 
umbilical, 213 

etiology of, 213 
treatment of, 213 
Herpes in cerebrospinal meningitis. 356 
of fauces, diagnosis of, from diph- 
theria, 395 
of tonsils, 591 
Hetero-infection in sepsis in newborn, 

201 
Hirschsprung's disease, 540 
History, maternal, 36 
parental, 37 
taking, 36 
Hochsinger's induration in hereditary 

syphilis, 453 
Hodgkin's disease, 747 

diagnosis of, from leukaemia, 
747 
from tuberculous adenitis, 
747 
lymph-nodes in, enlargement 
of, 747 
Hook-worm disease, 558 
Horner 's symptom, 40 
Huebner-Hoffman method of artificial 

infant-feeding, 135 
Hum, venous, 706 
Human milk. See Milk, human 
Huntington's chorea, 823 
Hutchinson's teeth in syphilis. 471 
Hydraemia without kidney lesion, 773 



INDEX. 



915 



Hydremia in simple anaemia, 737 
Hydrencephaloid, diagnosis of, from 
congenital internal hydrocepha- 
lus, 834 
expression of face, 40 
Hydrocele adnata, 182 
congenita, 182 

diagnosis of, 183 

from hernia, 183 
treatment of, 183 
Hydrochloric acid, decrease of, rachitis 
and, 238 
in newborn, 169 
Hydrocephalic form of idiocy, 878 
Hydrocephalus, 833 

acquired, diagnosis of, from con- 
genital internal hydrocephalus, 
835 
acute internal, 366, 432 
chronic, cerebrospinal fluid in, 76 
lumbar puncture in, 78 
diagnosis of, from rachitis, 
246 
external, 836 

diagnosis of, 837 

from congenital internal 
hydrocephalus, 835 
etiology of, 836 
pachymeningitis and, 836 
facial expression in, 39 
internal, congenital, 833 

cranial bones in, 834 
craniotabes in, 834 
diagnosis of, 834 

from acquired hydro- 
cephalus, 835 
from cranial syphilis, 

835 
from external hydro- 
cephalus, 835 
from hydrencepha- 

loid, 834 
from rachitis, 834 
etiology of, 833 
fontanelles in, 834 
idiocy in, 833 
paralysis in, 833 
pathology of, 833 
prognosis of, 835 
symptoms of, 833 
treatment of, 835 
in rachitis, 240, 245 
Hydromyelocele, 881 
Hydronephrosis, 784 

diagnosis of, from carcinoma of 
kidney, 787 
from cyst of kidney, 785 
Hydrorrhachis, 880 
Hydrotherapy, 64 

Hyperesthesia in cerebrospinal menin- 
gitis, 352 
Hyperthermia, sudden death and, 21 
Hypertrophy of heart, 709 
muscular, 49 

in pseudohypertrophic paral- 
ysis, 49 



Hypertrophy of thymus gland, 72 8 
thymus death in, 731 
Hypodermic administration of drugs, 64 
Hypodermoclysis, 66 

in acute gastro-enteric infection, 
525 

in cholera infantum, G6 
Hysteria, 802 

anaesthesia in, 804 

anorexia in, 804 

bradycardia in, 805 

catalepsy in, 803 

contortions in, 803 

convulsive forms of, 803 

dancing mania in, 804 

diagnosis of, 805 

from epilepsy, 821 
from tuberculous meningitis, 
805 

disturbances of sensation in, 804 
of vision in, 804 

epidemics of, 804 

etiology of, 802 

globus hystericus in, 803 

hyperassthesia in, 804 

hystero-epilepsy in, 803 

mental, 802 

motor manifestations in, 803 

non-convulsive, 802 

onset of, 803 

paralyses in, 804 

psychic, 802 

sex and, 802 

sexual organs in, abnormalities of, 
802 

symptoms of, 802 

tachycardia in, 804 

treatment of, 805 
Hystero-epilepsy and hysteria, 803 



Ichthyosis, congenital, 893 
symptoms of, 894 
treatment of, 894 
Icterus, catarrhal, 563 

gravis in newborn, 218 

infectious, 563 

neonatorum, 217 

etiology of, 218 
symptoms of, 218 
treatment of, 218 

in newborn, 217 

in sepsis of newborn. 1217 

simple, 563 
Idiocy. 876 

amaurotic, 837 

deep retloxes in. 839 
diagnosis o\', 839 
etiology o\\ 837 
juvenile form of, 839 
nystagmus in, 40 
ocular changes in. 839 
optio neuritis in. 839 
paralysis in. 838, 8 
pathology of, 838 



916 



INDEX. 



Idiocy, amaurotic, position of head in, 
35, 38 
prognosis of, 840 
spastic phenomena in, 51 
symptoms of, 838 
Tay-Kingdon 's spot in, 839 
in congenital internal hydroceph- 
alus, 833 
cretinic form of, 878 
epileptic form of, 878 
etiology of, 876 
facies in, 878 
family, 837 
genetous, 877 

hydrocephalic form of, 878 
management of, 879 
microcephalic form of, 877 
Mongolian, diagnosis of, from 
rachitis, 246 
from sporadic cretinism, 
724 
facial expression in, 40 
palpebral fissure in, 40 
paralytic form of, 878 
patellar reflex in, 49 
predisposition toward, 876 
sclerotic form of, 878 
symptoms of, 878 
syphilitic form of, 878 
treatment of, 879 
Idiopathic hemorrhage from umbilicus, 

212. See also Omphalorrhagia, true 
Ileocolitis, 528 

Ileotyphus, 318. See Typhoid fever 
Imperial granum, 121 
Impetiginous eczema, 885 
Incubator, 186 

cleansing of, 186 
indications for use of, 188 
infections due to, 186 
Lion's, 187 
Tarnier's, 186 
temperature in, 188 
Indican in urine, 33 
Indigestion, 502 
Infancy, convulsions in, 797 

definition of, 17 
Infant-feeding, 81 
artificial, 133 

Biedert's mixture, 133, 134 
Chapin's method of, 158 
colic in, 152, 153 
constipation in, 152 
dextrinized gruels in, 158, 159 
diluents in, 149 
from eighteenth month to end 

of second year, 162 
Escherich 's method, 135 
fat diarrhoea in, 153 
fat-percentages in, too high, 

148 
fats in, percentage of, 137 
formulae for, 147 
greenish movements in, 153 
Huebner-Hoffman method of, 
135 



Infant-feeding, artificial, Keller 's 
method of, 159 
laboratory method of, 133, 135 
Liebig's formula in, 159 
lime-water in, 149 
low percentage of fats in, 154 

of proteids in, 154 
malt extract in, 159 
Meigs' mixture for, 133, 134 
milk in, home modification of, 
140 
quantity of, 138, 139, 140 
milk in, raw, 110 
mixed, 132 
from ninth to twelfth month, 

160 
nursings in, frequency of, 138, 

139, 140 
over-feeding in, 132 
peptonization in, 154, 155 
percentage method of, 135, 136 

schedule for, 138 
percentages in calculation of, 

143, 144 
principles underlying, 81 
proteids in, percentage of, 137 
Eotch's method of, 133, 135 
salts in, percentage of, 131 
after sixth month, 160 
Soxhlet method of, 135 
spitting in, 152 
sugar in, percentage of, 137 
table of feedings for, 140 
thriving under, signs of, 150 
from twelfth to eighteenth 

month, 161 
vomiting in, 154 
whey method in, 155 
vomiting in, 132 
Infant-foods, artificial, 119, 120, 121 
carbohydrates in, 119, 121 
classification of, 119, 120 
composition of, 120, 121 
diastase in, 119 
fats in, 121 
malt extract in, 119 
objections to, 119, 121 
proteids in, 121 
rachitis from, 119 
scurvy from, 119 
sugar in, 121 

at time of weaning, 121, 122 
use of, indications for, 157 
in dyspepsia, 157 
in intestinal disease, 157 
utility of, 119 
varieties of, 119, 120 
Infantile atrophy, 260 
palsy, cerebral, 843 
paralysis, 861 
scorbutus, 254 
scurvy, 254 
typhoid fever, 319 
Infantilism, dental, in syphilis, 473 

diagnosis of, from sporadic cretin- 
ism, 725 



INDEX. 



917 



Infantilism, differentiation of, from 

dwarfism, 726 
Infants, artificially fed, metabolism in, 
88 
breast-fed, metabolism in, 85, 86 
congenitally weak, 183 

appearance of, 184 
asphyxia in, 198 
atelectasis in, 184 
bath of, 190 
bronchial nodes in, 184 
bronchitis in, 189 
bronchopneumonia in, 184, 

185 
clothing of, 190 
desquamation in, 184 
diarrhcea in, 185 
ductus Botalli in, 184 
etiology of, 183 
feeding of, 188 
artificial, 191 
breast, 190 
mixed, 192 
with modified milk, 

192 
with peptonized milk, 
192 
food of, amount of, 192 
gavage in, 189 
hemorrhages in, 184 
incubators for, 186 
infarctions in, 184 
infections in, 184 
intestines in, 184, 185 
meconium in, 185 
morbid anatomy of, 184 
nursing tube for, 188 

Breck's, 189,190 
pathology of, 184 
pericarditis in, 184 
pneumonia in, hemor- 
rhagic, 184 
prematurity and, 183. 
prognosis of, 185 
sclerema in, 184 
sepsis in, 184 
skin of, 184 
symptoms of, 184 
syphilis and, 184 
temperature in, 185, 186 
triplets and, 184 
tuberculosis and, 184 
twins and, 184 
weight in, 183, 185 
food of, 89 
marantic, feeding of, 159 

scurvy in, 159 
premature, 183 
Infarction, uric acid, 34, 775 
Infections, bacillary, of human milk, 97 
in childhood, 18 
filth, 18 
in newborn, 17 
otogenic, 202 
urogenital. 202 



Infectious diseases, acute, contra-indi- 
cation to maternal nursing, 
124 
bacteria of, in human milk, 97 
chorea and, 824 
muscular atrophy in, 49 
specific, 265 
vomiting in, 507 
icterus, 563 
myelitis, acute, 756 
Inflammatory bronchiectasis, 607 
Influenza, 339 
age and, 340 
albuminuria in, 344 
bacteriology of, 340 
bronchitis in, 342 
bronchopneumonia in, 341 
cerebrospinal meningitis in, 342 
cystitis and, 793 
diagnosis of, 344 

from lobar pneumonia, 629 
from measles, 306 
diarrhoea in, 341 
duration of, 344 
endocarditis and, 690 
endocarditis in, 341 
etiology of, 340 
eyes in, 341 
incubation of, 340 
infection in, mode of, 340 
mumps and, 372 
myocarditis in, 341 
in newborn, 340 
nephritis in, 341, 343 
otitis media in, 344 
pneumonia in, 342 

lobar, 341 
prognosis of, 344 
symptoms of, 341 
temperature in, 341 
treatment of, 344 
Inhalations, calomel, 68 

in acute laryngitis, 68 
Intermittent fever, 334 
Internal cephalhematoma, 234 
hydrocephalus, acute, 366 
acute, 432 
congenital, 833 
Intertrigo, 885 
Intestinal digestion, 497 
casein in, 498 
fats in, 499 
milk sugar in, 49S 
disturbances in childhood, 18 
obstruction, acute, 542 
vomiting in. 507 
Intestinal parasites, 555 
residue. 100 
secretions. 497 
walls, secretions of, 498 
Intestines, diseases of, 493 

perforation of. in dysentery. 532 
in typhoid fever. 328 
Intoxications, sudden death and. 21 
1 nt ra uterine rachitis, 237 
Intubation in diphtheria, 402 



918 



INDEX. 



Intussusception, 542 

abdomen in, 44, 45 

acute acquired constipation and, 
536 

diagnosis of, 545 

from acute appendicitis, 545 
from dysentery, 545 
from scurvy, 545 

etiology of, 542 

frequency of, 542 

hemorrhage in, 544 

onset of, 543 

prognosis of, 545 

rectal exploration in, 46 

spontaneous cure of, 546 

symptoms of, 543 

tenesmus in, 544 

treatment of, 546 

tumor in, 544 

varieties of, 542 

vomiting in, 543 
Iodine in human milk, 97 
Iron in human milk, 93 
Irregularity of pulse, 30 
Irrigation, rectal, 72 
Irritable heart, 700, 701 



Jaundice, 563 

bacteriology of, 563 

in congenital obstruction of bile- 
ducts, 564 

(enlargement of liver in, 564 
of spleen in, 564 

in newborn, 171 

occurrence of, 563 

pathology of, 563 

in phlebitis umbilicalis, 211 

simple, 563 

symptoms of, 563 

treatment of, 564 
Joint-crepitus, 46, 47 
Joints, affections of, 46, 47 

crepitus of, 46, 47 

examination of, 46 

motility of, 46 

palpation of, 46 



Keller's method of artificial infant- 
feeding, 159 
Keratin, 82, 84 
Kernig's symptom, 50 

in acute encephalitis, 860 

in cerebrospinal meningitis, 

352 
in meningism, 50 
in pneumonia, 50 
in tuberculous meningitis, 435, 

439 
in typhoid fever, 50 
Kidney, carcinoma of, 785 
diagnosis of, 787 

from cyst of kidney, 787 
from hydronephrosis, 787 



Kidney, enlargement of kidney in, 
786 
hematuria in, 786 
symptoms of, 786 
cysts of, 784 

diagnosis of, from hydrone- 
phrosis, 785 
diseases of, 770 
enlargement of, in carcinoma of 

kidney, 786 
floating, 45, 770 
new growths of, 784 
palpation of, 770 
in pseudoleuksemic anaemia, 740 
sarcoma of, 785 

diagnosis of, 785 
symptoms of, 785 
tuberculosis of, 787 
diagnosis of, 788 
symptoms of, 787 
urine in, 787 
tumors of, 784 

diagnosis of, from tumor of 

spleen, 739 
simulating tumor of liver, 562 
treatment of, 788 
weight of, 770 
Kissing, development of, 36 
Klebs-Loffler bacillus in diphtheritic 

rhinitis, 578 
Koch's peptone, 116 
Koplik's spots in measles, 298 
Kumyss, 117 



Lab-fermext. digestive action of, in 

stomach, 496 
Labia, cellular atresia of, dvsuria in, 

773 
Lactalbumin in cows' milk, 102 

in human milk, 84, 92 
Lactic acid in cows' milk, 102, 103 

increase of, rachitis and, 238 
Lactobutyrometer, Conrad's, 100 
Lactodensimeter, Conrad 's ; 100 

Quevenne's, 100 
Lactoglobulin in human milk, 92 
La Grippe, 339. See also Influenza 
Landouzy type of f acio-scapulo-humeral 

muscular atrophy, 873 
Lanugo, 170 
Laryngeal chorea, 822 
diphtheria, 387 
dyspnoea, 614 
stridor, 816 
Laryngismus stridulus, 816 
apncea in, 817 
complications of, 819 
craniotabes and, 817 
diagnosis of, 818 

from diphtheria, 394 
etiology of, 817 
pathology of, 817 
prognosis of, 818 
rachitis and, 817 



INDEX. 



919 



Laryngismus stridulus, symptoms of, 
817 
thymus in, enlargement of, 817 
treatment of, 819 
Trousseau 's phenomenon in, 
818 
Laryngitis, acute, calomel inhalations 
in, 68 
vapor spray in, 68 
catarrhal, 593 

diagnosis of, 594 

from diphtheria, 593, 594 
etiology of, 593 
prognosis of, 594 
symptoms of, 593 
treatment of, 594 
phlegmonous, 594 
spasmodic, 593 
submucous, 594 
Laryngospasm, tetany and, 812 
Larynx, diseases of, 593 
foreign bodies in, 597 
prognosis of, 597 
symptoms of, 597 
treatment of, 597 
syphilis of, 596 

diagnosis of, 596 
prognosis of, 596 
treatment of, 596 
tuberculosis of, 432, 596 

treatment of, 596 
tumors of, 596 

symptoms of, 596 
treatment of, 597 
varieties of, 596 
Latent tetany, 812 
Laughing, development of, 35 
Lecithin, 82 

in human milk, 92, 93 
Length of body, 26 
Lepto-meningitis, acute, 363 
diagnosis of, 364 
etiology of, 363 
symptoms of, 364 
Leucocytes, 735 

in newborn, 169 
Leucocytosis in scarlet fever, 280 
Leukaemia, 743 

blood in, changes in, 744 
bone-marrow in, 744 
diagnosis of, from Hodgkin's dis- 
ease, 747 
enlargement of lymph-nodes in, 716 
etiology of, 743 
lymphatic, 743 
lymph-nodes in, 746 
myelogenous, 743 
prognosis of, 747 
rachitis and, 743 
skin in, 745, 746 
spleen in, enlargement of, 744 
symptoms of, in acute form, 744 

in chronic form, 746 
syphilis and, 743 

l reatment of, 747 



Leukocytha3mia, 743 

Lewi's method of estimation of fats, 

100, 101 
Lichen scrof ulosorum in scrofulosis, 413 
Liebig's beef -extract, 118 

formula in artificial infant-feeding, 

159 
peptone, 116 
Lime-water in artificial infant-feeding, 

149 
Limping gait, 51 
Lion 's incubator, 187 
Lip reflex, 468 

in newborn, 176 
Lipase, in cows' milk, 94 

in human milk, 94 
Liquid peptonoids, 116 
Lithsemia, 775 
Lithiasis, 38 
Little's disease, 843 
Liver, abscess of, 566 

etiology of, 566 
symptoms of, 566 
treatment of, 567 
acute yellow atrophy of, 567 
carbohydrates in, 85 
cirrhosis of, 565 
age and, 565 
enlargement in, 565 
etiology of, 565 
pathology of, 565 
symptoms of, 565 
diseases of, 560 

contra-indication to maternal 
nursing, 124 
displacement of, in empyema, 662 
dulness of, 44 
enlargement of, 562 

in abscess of liver, 566 

in anaemia infantum pseudo- 

leukaemica, 562 
in cirrhosis of liver, 565 
in congenital obstruction of 
bile-ducts, 564 
syphilis, 563 
empyema simulating, 562 
in fatty degeneration of liver, 

565 
in jaundice, 564 

normal rotation simulat- 
ing, 561 
in pseudoleukamiic anae- 
mia, 740, 741 
in rachitis, 562 
in Still's disease, 563 
subphrenic abscess simulating, 
562 
examination of, 560 
fatty degeneration of, 565 
measurements of, 561 
normal rotation of, simulating en- 
largement of liver, 501 
palpation of, 560 
parasites o\\ 567 
percussion o\'. "nil 
in rachitis. 239. 245 



920 



IXDEX. 



Liver, secretions of. 498 

in sepsis in newborn. 204 
syphilis of. 565 
tumor of, 567 

kidney tumor simulating, 562 
phantom. 562 
weight of. 560 
Lobar pneumonia: 615 
Lobular pneumonia. 632 
Lordotic albuminuria. 770 
Lourie, crescents of. 89, 90 
Lumbar puncture, 74 

in acute encephalitis, 861 

in cerebrospinal meningitis, 

357, 360, 361 
danger of. 79 

fluid withdrawn, amount of. 79 
in hydrocephalus, chronic. 7S 
indications for. 77 
in meningism, 77 
in meningitis, 77, 78 
operation of, 77 
in pneumonia, 78 
in sepsis in newborn, 205 
in status epilepticus. 77 
sudden death in. 22 
in tetanus of newborn, 217 
Lungs, atelectasis of. 198 

collapse of. 198. See also Atelectasis 
diseases of, 610 
emphysema of, 601 
gangrene of, in bronchiectasis. 609. 
610 
bronchopneumonia and, 640 
induration of. in lobar pneumonia. 

617 
limits of, normal, 611 
in newborn, 166 
size of, 610 
Lupus in scrofulosis, 413 
Luschka's tonsil. 5S0 
Lymph, carbohydrates in. 85 
Lymphadenitis, acute, 716 
chronic, 717 

symptoms of. 717 
treatment of. 717 
retropharyngeal, 585 
Lymphadenoma. 747 
Lymphangitis of breast. 129 
Lymphatic leukaemia , 743 
Lymphatism, adenoid growths and, 580 
chorea and, S23 
chronic nasal catarrh and, 576 
emphysema of lungs and. 602 
enlargement of lymph-nodes in. 715 
sudden death and. 22 
thymus death and. 729 
gland and, 729 
Lymph-nodes, diseases of, 715 

enlargement of, in adenoids, 715 
in anaemia. 716 
in balanitis. 715 
in congenital syphilis. 715 
in disease of ear. 715 

of scalp. 715 
in exanthemata. 715 



Lymph-nodes, enlargement of, in Hodg- 
kin-'s disease, 716 

in leukaemia, 716 

in lymphatism. 715 

in parotitis, 715 

in rachitis. 716 

in retropharyngeal adenitis, 

715 
in tonsillar infection, 715 
in tuberculosis, 715 
in leukaemia. 746 
in measles, 304 
in rachitis. 239 

in scarlet fever. 270. 273, 276, 
2S9 
Lymphosarcomata. 716 

M 

McBurxey "s point in acute appendi- 
citis, 550 
Macewen's sign in cerebrospinal men- 
ingitis, 353 

in tuberculous meningitis, 441 
Macroglossia. 484 

congenita hypertrophica, 484 

lymphatica. 484 
in sporadic cretinism, 722 
Mala die de Eoger, 689 
Malarial fever, 334 

age and, 335 

blood in, 336 

diagnosis of. 337 

etiology of, 335 

incubation in, 335 

mosquitoes and. 335 

onset of, 336 

parasite of. 335 

pathology of, 336 

prognosis of. 338 

quinine and, 338, 339 

relapses in, 337 

symptoms of, 336 

temperature in. 337 

treatment of, 338 
Malignant disease, contra-indication to 
maternal nursing, 124 
endocarditis. 696 
purpuric fever, 347 
Malt-extract in artificial infant-feeding, 

159 
Manhu infant food, 120 
Marantic infants, sudden death in, -20 
Marasmus. 260 
Mastitis in newborn, 231 

treatment of, 232 
Mastoid disease, 765 

age and, 765 

course of, 768 

diagnosis of, 768 

etiology of, 765 

exanthemata and, 766 

facial palsy and, 851, S52 

measles and, 766 

otoscopic examination in, 767 

pain in, 767 



INDEX. 



921 



Mastoid disease, physical signs of, 767 
prophylaxis of, 768 
scarlet fever and, . 273, 276, 

766 
swelling in, 767 
symptoms of, 765 
temperature in, 765, 766 
treatment of, 768 
tumefaction in, 767 
typhoid fever and, 766 
region, anatomy of, 765 
Mastoiditis in typhoid fever, 326 
Masturbation, 807 

treatment of, 807, 808 
Maternal nursing, 122 

contra-indications to, 123 

in acute infectious dis- 
eases, 124 
in Bright 's disease, 124 
in heart disease, 124 
in liver disease, 124 
in malignant disease, 124 
in organic nervous dis- 
ease, 124 
in syphilis, 123 
in tuberculosis, 123 
Measles, 294 

acute infectious osteomyelitis and, 

757 
amaurosis in, 304 
atelectasis and, 302 
blood in, 304 
bones in, 304 

bronchitis and, 302, 308, 309 
bronchopneumonia and, 302, 308, 

309, 639 
buccal mucous membrane in, 298 
complications of, 300, 308 

treatment of, 308 
conjunctivitis in, 295, 304 
contagiousness of, 295 
corneal ulcerations in, 304 
coryza in, 294, 295, 296 
cystitis and, 793 
desquamation in, 295, 296 
diagnosis of, 306 

from antitoxin eruptions, 307 
from drug eruptions, 307 
from influenza, 306 
from rotheln, 306 
from scarlet fever, 282, 306 
from syphilitic roseola, 307 
from typhoidal roseola, 307 
diarrhoea in, 303, 310 
diphtheria and, 301, 309, 396 
ear in, 305 



enanthema 



IDS 



endocarditis and, 303, 690 
eruption in, 296 
exanthema in, 296, 300 
eyes in, 309, 310 
firstborn and, 294 
foetus and, 294 
gangrene of pinna in, 305 
genitals in, 305 
German, 291. See Rotheln 



Measles, heart in, 303 
immunity from, 294 
incubation of, 294 
intestines in, 303 
joints in, 304 
kidneys in, 304 
Koplik's spots in, 298 
larynx in, 301, 309 
lymph-nodes in, 304 
mastoid disease and, 766 
meningitis and, cerebrospinal, 304 
mouth in, 298, 305, 310 
mumps and, 372 
myocarditis in, 303 
nephritis in, 304 
nervous system in, 304 
neuritis and, 304 
newborn and, 294 
noma in, 305 
nose in, 300, 310 
otitis in, 305 
pericarditis in, 303 
pertussis in, 305 
pharynx in, 300, 301 
photophobia in, 296, 304 
pneumonia and, 301, 302 
prognosis of, 305 
prophylaxis of, 307 
sequelae of, 305 
stomatitis in, 305 
symptoms of, 295 
temperature in, 296 
treatment of, 308 
Meconium, 174 

analysis of, chemical, 175 
bacteria in, 175 
bilirubin in, 174 
bodies, 174, 175 
color of, 174 
composition of, 174 
in congenitally weak infants, 1S5 
consistency of, 174 
odor of, 174 
plug, 174 
quantity of, 174 
Medulla, tumors of, 843 
Meigs' mixture, 133, 134 
Melaena neonatorum, 219 

bacillary infection and. 220 

diagnosis of, 221 

etiology of, 219 

pathology of, 220 

prognosis of. 221 

symptoms of, 220 

treatment of. 221 
Melancholia in diphtheria. 392 
in lobar pneumonia, 023 
pertussis convulsiva and. 370 
in scarlet fever. 279 
Moll in-'s food. 120 
Memory, development of. 30 
Meningism, Kernig's symptom in. 30 

lumbar puncture in. 77 
Meningitis, 809 

acute encephalitis and. 860 
basilar. 132 



922 



IXDEX. 



Meningitis, boat-shaped abdomen in. 44 
bronchopneumonia and. 642 
cerebrospinal, 347 
age and. 349 
Babinski reflex in. 352 
bacteriology of, 357 
blood in. 354 
complications of, 356 
cytology of. 357 
diagnosis of, 358 

from acute poliomvelitis. 
871 

from meningitis serosa, 
368 

from pneumonia, 359 

from tetanus of newborn, 
216 

from tuberculous menin- 
gitis, 358 

from typhoid fever, 358 
diet in, 362 

diplococcus intracellularis in, 
347 

pneumoniae in, 34S 
ear in, 356 
eechymoses in, 350 
endocarditis and, 690 
epidemic, 348 

cerebrospinal fluid in, 76 
etiology of, 347 
eyes in, 353 
facial paresis in, 353 
Flexner's serum in, 360 
fontanelle in, 356 
herpes in, 356 
hydrotherapy in, 362 
hypersesthesia in, 352 
infection in, mode of, 348 
in influenza, 34^ 
Kernig symptom in, 352 
leucocyte count in, 354 
lumbar puncture in, 357, 360 
Macewen's sign in, 353 
measles and, 304 
mydriasis in. 354 
neck rigidity in, 352 
onset of, 349. 350. 351 
opisthotonos in. 352 
paralysis in. 353 
pathology of, 349 
prognosis of. 359 
pulse in, 354 
reflexes in, 352 
respiration in, 354 
sequelae of. 357 
skin in. 356 
spleen in, 356 
sporadic, cerebrospinal fluid 

in, 76 
symptoms of. S49 

cerebral. 351 
tache cerebrale in. 352, 359 
temperature in, 355 
treatment of, 360 
diagnosis of, from convulsions in 
infancv, 800 



Meningitis, diagnosis of. from lobar 
pneumonia, 629 
from typhoid fever, 330 
lobar pneumonia and, 627 

lumbar puncture in, 77, 7S 
in phlebitis umbilicalis. 211 
position of head in, 38 
posterior basic. 364 

complications of. 365 
etiology of, 364' 
hydrocephalus in, 365 
occurrence of, 364 
opisthotonos in. 365 
rigidity in, 365. 366 
symptoms of, 365 
treatment of, 366 
in scarlet fever, 275 
serosa, 366 

cerebrospinal fluid in, 368 
diagnosis of, 368 

from meningitis, cerebro- 
spinal, 368 
tuberculous, 368 
from otitis media puru- 
lenta, 368 
etiology of, 367 
lumbar puncture in, 368 
occurrence of, 366 
pathology of, 367 
spine in, 47 
suppurative, cerebrospinal fluid in. 

76 
tuberculous, 432 

Babinski ; s reflex in. 49. 50. 

435. 439 
bacteriologv of. 441 
blood in, 440 
cerebral cry in, 440 
cerebrospinal fluid in, 76 
Chevne-Stokes respiration in. 

434, 439 
Chvostek-'s symptom in, 435 
diagnosis of, differential. 442 
from cerebrospinal menin- 
gitis, 358 
from meningitis serosa, 
368 
etiology of, 432 
eyes in, 440 
facial paralysis in. 435 
hyperesthesia in, 439 
in hysteria, 805 
Kernig 's symptom in, 435,439 
lumbar puncture in, 441 
Macewen's sign in, 441 
occurrence of, 432 
onset of, 438 
pathology of, 432 
prognosis of. 443 
pulse in. 439 
respiration in, 439 
rigidity in, 438 
symptoms of, 433 
treatment of, 443 
Trousseau's symptom in. 435 
tuberculin test in. 442 



INDEX. 



923 



Meningitis, tuberculous, vomiting in, 438 
vertical, 363. See Lepto-meningitis, 

acute 
vomiting in, 508 
Meningocele spinalis, 881, 883 
Meningococcus meningitis, 347 
Meningo-encephalocele, 880 
Menstruation, effect of, on human milk, 

98 
Mental development, 34, 35, 36 

hysteria, 802 
Mesenteric glands, tuberculosis of, 431 
Metabolism in newborn, 177 
Metapneumonic pleurisy, 657 
Microcephalus, forms of, 877 

premature closure of f ontanelles in, 
38 
Microdontism in syphilis, 473 
Micromelia, 250 
Milia in newborn, 171 
Miliaria alba, 892 

rubra, 892 
Miliary tuberculosis, 421 
Milk, animal, comparison of, with hu- 
man milk, 92 
boiled, assimilation of, 109 
breast-. See Milk, human, 
burette, Woodward's, 102 
condensed, 113 

composition of, 113 
dilution of, 113, 114 
in gastro-enteritis, 113, 114 
rachitis from, 113 
scurvy from, 113 
cows', 102 

acidity of, 106 
albumin in, 102 
bacteria in, 104, 105 
Bacterium lactis aerogenes in, 

105, 106 
Bacillus mesentericus vulgatus 
in, 105 
subtilis in, 105 
calories in, 86 
carbohydrates in, 85 
casein 'in, 91, 102, 103 
composition of, 102 
diluents for, 149 
fats in, 84, 102, 103 
infected, 105 

cholera asiatica and, 105 
diphtheria and, 105 
dysentery and, 105 
scarlet fever and, 105 
tuberculosis and, 105 
lactalbumin in, 102 
lactic acid in, 102, 103 
lipase in, 94 
mineral salts in, S3 
pasteurization of, 106 
phosphorus in, 103 
potato bacillus in, 105 
proteids in, 103 
reaction o\\ 102 
specific gravity of. 102 
sterilization o\', 107 



Milk, cow's, sugar in, 102 

water in, 102 
frozen, 111 

constipation from, 111 

diarrhoea from, 111 

fat-globules in, 111 
human, 90 

agglutinins in, 97, 98 

alcohol and, 97 

alexins in, 17, 88, 89, 94, 95 

amount of, daily, 96 

amylase in, 94 

analysis of, 99 

antitoxins in, 97, 98 

bacteria in, 94 

bacillary infection of, 97 

calories in, 86 

carbohydrates in, 85 

casein in, 84, 91, 92, 103 

caseinogen in, 91 

changes in, daily, 96 

chemistry of, 91, 92, 93 

colostrum in, 89 

comparison of, with animal 
milk, 92 

composition of, 91, 92 

consumption of, daily, 95 

at nursings, individual, 95 

crescent-shaped bodies in, 93 

diphtheria and, 97, 98 

drugs in, 97 

effect of beer on, 96 
of coffee on, 97 
of foods on, 96 
of menstruation on, 98 
of pregnancy on, 99 
of starvation on, 96 
of tea on, 97 

enzymes in, 88, 89, 94 

fats in, 84, 93, 100 

estimation of, 100, 101 

fatty acids in, 93 

ferments in, 94 

first appearance of, 90 

foreign substances in, 97 

iodine in, 97 

iron in, 93 

Konig's analysis of, 91 

lactalbumin in, S4. 92 

lactoglobulin in, 92 

lecithin in. 92, 93 

lipase in, 94 

mineral salts in. S3 

nucleon in, 93 

opalisin in. 92 

proteids in. 92 

estimation of, 102 

reaction of. 93. 94 

salicylic acid in, 97 

salts in. 93 

specific gravity of. 94. 99. 100 

Staphylococcus albus in. 94 

tetanus and. 98 

toxins in. 97. 98 
tuberculosis and. 97. 98 
typhoid fever and. 97. 98 



924 



INDEX. 



Milk, human, water in. S2 

whey proteids in. 91 
modified, 140 

in congenitallv weak infants, 

192 
formula? for, 14 < 
in newborn, 171 

pasteurized, assimilation of, 109 
peptonized, 112. 154, 155 

in congenitallv weak infants, 

192 
preparation of. 112 
powder, peptogenic, 112 
raw, assimilation of, 109 
diarrhoea from, 110 
in infant feeding. 110 
from limited herd, 110 
sterilized, assimilation of, 109 

bone disturbances from, 110, 

111 
constipation from, 108 
scurvy from. 108 
sugar, 85 

digestion of, 497, 498 
teeth. 470 

test for cleanliness of. 143 
top, 141 

home-made, 143 
seven per cent.. 142 
twelve per cent., 142 
of wet-nurse, 126 

nail-test for, 126 
witches', 171 
Mineral salts, in cows' milk, 83 
in human milk. 83 
percentage of, S3 
required by infants, S7 
role of, in nutrition, 83 
Mongolian idiocv, facial expression in, 
40 
palpebral fissure in, 40 
Monorchism, 182 
Morbidity in childhood, 17 

in newborn, 17 
Morbilli, 294. See Measles 

hemorrhagica, 300 
Morbus maculosus AVerlhofii, 749 
Moro's inunction tuberculin test, 424 
Mortality, 18, 19 

artificial feeding and, 18 
Mouth, angles of, ulcerations of, 475 
diagnosis of, 475 
etiology of. 475 
symptoms of. 475 
bacteria of, 62, 469 
care of, 61 
diseases of, 468 
ferment of, 468 
gonorrheal infection of, 481 
symptoms of. 4S2 
treatment of, 482 
normal, landmarks of. 469 
in scarlet fever. 271, 276 
ulceration of, 62 
washing of, 61, 62 



Mouth-breathing, adenoid growths and, 
581 
facial expression in, 39 
Mouth-to-mouth method of artificial 

respiration, 196 
Movements, habit, 831 
Mucin, 82, 84 
Mucous membranes in newborn. 17 

in rotheln, 292 
Multiple neuritis, 854 
Mumps, 368 

age and, 369 
albuminuria in, 371 
diagnosis of. 372 
etiology of . 368 
incubation in, 369 
influenza and, 372 
lymph-nodes in. 370 
measles and, 372 
metastasis of, 371 
otitis and, 371 
pathology of, 369 
pneumonia and, 371 
prognosis of. 372 
symptoms of, 370 
treatment of, 372 
typhoid fever and, 372 
urine in, 371 
varicella and, 372 
Murmurs, cardiac, 704 
accidental, 705 

arterial. 706 
anaemic, 705 
aortic, 705 
in chorea, 828 
dynamic. 705 
febrile, 705 
Muscles, carbohydrates in, 85 
Muscular atrophy, 49 
hypertrophy, 49 

paralysis, pseudohypertrophic, 873 
power in newborn, 175 
rheumatism, 467 
sense in newborn. 175 
Myocarditis, 706 

adherent pericardium and, 681 

arrhythmia in, 708 

bacteria and, 706 

bacteriology of, 707 

bradycardia in, 708 

chronic valvular disease of heart 

and, 708 
diagnosis of, 708 
diphtheria and, 707 
dyspnoea in, 708 
etiology of, 706 
exanthemata and, 706 
gallop-rhythm in, 708 
in influenza, 341 
in measles, 303 
pathology of. 706 
in pericarditis, 675 
pertussis and, 708 
pneumonia and, 708 
poisons and. 706 
pulse in, 708 






INDEX. 



925 



Myocarditis, pulse-respiration ratio in, 
708 

in scarlet fever, 279 

septic conditions and, 708 

symptoms of, 707 

toxic, 707 

toxins and, 706 

treatment of, 708 
Mydriasis in cerebrospinal meningitis, 

354 
Myelocystocele, 881, 882 
Myelogenous leukaemia, 743 
Myelomeningocele, 880, 881, 882 
Myotonia, 815 

N 

Nanism, 720" 
Nasal catarrh, acute, 574 
chronic, 576 
polypi, diagnosis of, from adenoid 
growths, 583 
Nasopharynx, diseases of, 574 
Neave's food, 121 

Nephritis, acute, bacteria and, 776, 777 
constipation in, 780 
diffuse, 776, 777 
duration of, 781 
dysentery and, 778 
etiology of, 776 
exudative, 776, 777 
fainting spells in, 780 
gastro-enteritis and, 778 
headache in, 780 
heart in, 780 

infectious diseases and, 776 
lungs in, 780 
oedema in, 780 
parenchymatous, 776, 777 
pathology of, 777 
primary forms of, 781 
productive, 776 
pulse in, 780 
scarlet fever and, 776 
symptoms of, 778 
temperature in, 780 
toxins and, 776, 777 
treatment of, 782 
urine in, 778, 779, 780 
vomiting in, 779 
chronic, diffuse, 781 

symptoms of, 781 
treatment of, 782 
productive, 781 
without exudation, 781 
diagnosis of, from cyclic albumi- 
nuria, 772 
diphtheria and, 389 
enema in, 73 

in follicular amygdalitis, 590 
glomerular, 776 
in influenza, 341, 343 
in measles, 304 

oedema of, diagnosis of, from scler- 
ema adiposum, 227 
in scarlet fever. 277, 278, 289 



Nephritis, tubular, 776 

in varicella, 312 
Nervous disease, organic, contra-indi- 
tion to maternal nursing, 124 
system, disease of, sudden death in, 
21 
diseases of, 797 
in newborn, 175 
in rachitis, 245 
in sepsis in newborn, 203 
Nestle 's food, 120 
Neuritis, measles and, 304 
multiple, 854 

chorea and, 825 
diagnosis of, 855 

from acute poliomyelitis, 
871 
etiology of, 854 
paralysis in, 855 
pathology of, 854 
sensory disturbances in, 855 
symptoms of, 854 
treatment of, 856 
wrist-drop in, 855 
muscular atrophy in, 49 
optic, in amaurotic idiocy, 839 

in tumor of brain, 841 
patellar reflex in, 49 
Newborn, acute infectious osteomyelitis 
and, 757 
amylolytic ferments in, 169 
anomalies in, 181 
asphyxia in, 193 
atelectasis in, 198 
bacteria and, 17, 18 
barley-gruel in, use of, 157, 158 
bile in, 169 
blood in, 168 
body-temperature in, 170 

fluctuation in, 170 
breasts in, 171 
caking of breasts in. 231 
cephaloha?matoma in, 234 
cerebrum in, 175 
circulation in, 167 
cold sense in, 177 
color of, 170 
deafness in, 176 
desquamation in, 17, 170 
digestion in, of alouminoids. 169 
of fats, 169 
of starch, 169 
digestive functions in, 169 
diseases of, 165 
ductus Botalli in. 167 
electrical stimulation in. 1 7 -" 
epidemic hemoglobinuria in. 222 
excretion in, 17? 
eye reflexes in. 176 
acute tatty degeneration of, 221 
diagnosis of, 222 
etiology of, 221 
hemorrhages in. 2 IP 
pathology of, 222 
prognosis of, 222 



926 



INDEX. 



Newborn, acute fatty degeneration of, 
in sepsis in new- 
born, 201 
symptoms of, 222 
treatment of, 222 
hsematoma of sternomastoid muscle 

in, 233 
hearing in, 176 
heat sense in, 177 
hemorrhages in, 219 
hydrochloric acid in, 169 
icterus in, 217 

gravis in, 218 
infections in, 17 
jaundice in, 171 
lanugo in, 171 
lip reflex in, 176 
lungs in, 166 

aeration of, 166 
mastitis in, 232 
meconium in, 174 
. mehena in, 219 
metabolism of, 177 
milia in, 171 
morbidity in, 17 
mortality of, 179 
motion in, 175 
mucous membranes in, 17 
muscular power in, 175 

sense in, 175 
nervous system in, 175 
ophthalmia of, 228 
pain sense in, 176 
pancreatic secretion in, 169 
paralysis in, 232 
patellar reflex in, 175 
pemphigus of, 894 
pepsin in, 169 
peritonitis of, 213 
perspiration of, 171 
physiology of, 165 
pulse in, 168' 

arrhythmia of, 168 
rectal excreta in, 174 
respiration in, 165 
saliva in, 169 
sclerema in, 224 

adiposum in, 224 
secretion of parotid gland in, 169 

of submaxillary gland in, 169 
sepsis in, 201 

auto-infection in, 202 

bacteria in, 201 

Bednar's aphtha? in, 203 

blood-cultures in, 204 

bones in, 203 

bronchitis in, 201 

Buhl's disease in, 201 

dermatitis exfoliativa and, 201 

diagnosis of, 204 

diarrhoea in, 201, 205 

digestive tract in, 202, 204 

ears and, 202 

Epstein's pearls in, 203 

etiology of, 201 

eyes and, 202 

hemorrhage in, 204, 219 



Newborn, sepsis in, hemorrhagic condi- 
tions in, 201 

hetero-infection in, 201 

joints in, 203 

liver in, 204 

lumbar puncture in, 205 

mouth in, 203 

nervous system in, 203 

pathology of, 204 

pericarditis in, 204 

pneumonia in, 201, 206 

prognosis of, 205 

pseudomembranous deposits in, 
203, 205 

respiratory tract in, 202, 204 

skin in, 202 

splenic puncture in, 205 

symptoms of, 202 

temperature in, 204 

treatment of, 205 

umbilicus and, 202, 203 

urine in, 204 

urogenital tract and, 202 

vagina in, 203 

weight in, 204 

Winckel's disease in, 201 
.septic infection of, 201 
skin in, 170 

reflex in, 175 
smell in, 176 
sudden death in, 179 
syphilitic, hemorrhages in, 219 
taste in, 176 
temperature in, 170 
tetanus of, 214 
touch sense in, 176 
umbilical arteries in, 167 

veins in, 168 
urea in, 173 
uric acid in, 173 
urine in, 172 

albumin in, 174 

in bottle-fed, 172 

in breast-fed, 172 

easts in, 173 

color of, 173 

reaction of, 173 

specific gravity of, 173 

urea in, 173 

uric acid in, 173 
vagus nerve in, 175 
vernix caseosa, 170 
waste in, 177 

weight of, decrease in, 179 
Winckel's disease in, 222 
"witches' milk" in, 171 
Night -terrors, 821 
Mpples of bottles, care of, 62 
of breast, care of, 61 
care of, after nursing, 129 
fissured, 128 

prevention of, 128 

shield for, Davidson's, 128 

treatment of, 129 
Nitroglycerine, dosage of, 64 
Noma, 483 



INDEX. 



927 



Noma, bacillus of Babes in, 483 
of diphtheria in, 483 

etiology of, 483 

in measles, 305 

prognosis of, 484 

symptoms of, 483 

treatment of, 484 
Non-convulsive hysteria, 803 
Normal children, variations in, 22, 23 
Nose, congenital syphilis of, 574 

diseases of, 574 
% examination of, 574 

foreign bodies in, 578 

symptoms of, 578 
treatment of, 579 

septum of, deformity of, 574 

syringing of, 66 
Nucleon in human milk, 93 
Nursery, 59 

temperature of, 59, 60 
Nursing, beginning of, after birth, 127 

bottle, 111 

frequency of, 127 

infant, metabolism in, 85 

lip reflex in, 468 

maternal, 122 

physiology of, 468 

tube, 188 

Breck's, 189, 190 
Nutation, nystagmus in, 40 
Nutrition, 81 

disturbances of, diseases due to, 
237 

principles underlying, 81 
Nutroa food, 121 
Nystagmus, 40, 832 

in albinism, 40 

in amaurotic idiocy, 40 

in congenital cataract, 40 

in corneal cataract, 40 

in hereditary ataxia, 858 

in infantile amblyopia, 40 

in nutation, 40 

in rachitis, 40 

rhythmic movements of head and, 
832 

in spasms, 40 



Oatmeal, composition of, 115 
gruel, 114 

preparation of, 114 
Obstetrical palsy, 855 
Occipital lobe, tumors of, 841 
O'Dwyer's tubes in diphtheria, 402 
(Edema in acute nephritis, 780 
glottidis, 594 
of glottis, 594 

etiology of, 595 

infectious diseases and, 595 

pathology of, 595 

prognosis of, 595 

symptoms of, 595 

i rauma and. 595 

t reatment of, 595 



Oedema of glottis, without kidney 
lesion, 773 
of nephritis, diagnosis of, from 
sclerema adiposum, 227 
Oesophagitis, 490 
caustic, 490 

etiology of, 490 
symptoms of, 490 
treatment of, 491 
Oesophagus, branchial cysts of, 488 
fistulse of, 488 
congenital anomalies of, 488 
stricture of, 489 
absence of, 490 
atresia of, 490 
diseases of, 488 
diverticula of, 488 
hysterical stricture of, 803 
traumatic stricture of, 490 
Olein, 84 
Omphalorrhagia, 211 

in faulty ligation of cord, 211 
true, 212 

in congenital syphilis, 212 
etiology of, 212 
in fatty degeneration, 212 
in septic infections, 212 
symptoms of, 212 
treatment of, 213 
Omphalitis, 206 
Onychia in typhoid fever, 327 
Opalisin in human milk, 92 
Ophthalmia, diphtheria and, 392 
gonorrhoea!, 55, 56, 228 
neonatorum, 228 

blindness and, 228 
complications of, 229 
Crede method in, 230 
diagnosis of, 229 
etiology of, 228 
prognosis of, 230 
prophylaxis of, 230 
symptoms of, 229 
treatment of, 230 
Opisthotonos in cerebrospinal menin- 
gitis, 352 
in lobar pneumonia, 623 
Opmus food, 121 
Orthopnea in pericarditis, 676 
Orthostatic albuminuria, 770 
Osteochondritis in hereditary syphilis, 

454 
Osteogenesis imperfecta. 252 
diagnosis of, 253 

from chondrodystrophia 

f ©talis, 253 
from rachitis. 253 
from syphilis. 2.";; 
etiology of, 253 
pathology ot\ 252 
symptoms of, 252 
traumatism and. 253 
treat moot o\\ 254 
Osteomyelitis, acute infectious. 756 
bacteriology of. 756 
bones in. changes <* 



928 



INDEX. 



Osteomyelitis, acute infectious, diag- 
nosis of, 758 
from congenital syph- 
ilis, 758 
from scorbutus, 758 
from tuberculous in- 
flammation, 758 
etiology of, 756 
measles and, 757 
in newborn, 757 
pathology of, 757 
pneumonia and, 757 
prognosis of, 758 
scarlet fever and, 757 
symptoms of, 757 
treatment of, 758 
bronchopneumonia and, 692 
endocarditis and, 690 
Otitis, bacteriology of, 759 
bones in, change in, 760 
bronchopneumonia and, 640, 759, 

761 
cerebral abscess and, 760 
diagnosis of, 764 
etiology of, 759 
examination of ear in, 762 
exanthemata and, 759 
exfoliated epithelium in, 764 
exudates in, 760 
facial palsy and, 851 
in follicular amygdalitis, 590 
lobar pneumonia and, 626 
in measles, 305 
media catarrhalis, 759, 760 
in influenza, 344 
purulenta, 759, 760 

diagnosis of, from menin- 
gitis serosa, 368 
mumps and, 371 
pathology of, 759 
perforation of drum in, 761 
pneumonia and, 761 
prognosis of, 764 
in scarlet fever, 273, 290 
in scrofulosis, 414 
symptoms of, 760 
tympanic membrane in, 759 
tympanum in, appearance of, 764 
in typhoid fever, 326 
in varicella, 313 
Otogenic infections, 202 
Ovaries, metastasis of mumps to, 371 
Over-feeding in mixed infant-feeding, 

132 
Oxyuris vermicularis, 557 

treatment for, 557 
Ozaena in scrofulosis. 413 



Pack, cold, 65 

Pachymeningitis, external hydrocepha- 
lus" and, 836 
Pain sense in newborn, 176 
Palmitin, 84 
Palpation of chest, 43 



Palpebral fissure, 40 
Palsy, birth, 232, 843 

cerebral, birth, diagnosis of, from 
Erb's palsy, 857 
diagnosis of, from acute polio- 
myelitis, 871 
patellar reflex in, 49 
infantile, 843 
acute, 850 
aphasia in, 848 
athetosis in, 848 
contractures in, 846 
convulsions in, 845 
diagnosis of, 850 

from infantile paral- 
ysis, 850 
diplegia in, 844 
epilepsy in, 845, 849 
etiology of, 843, 845 
gait in, 846 
hemiplegia in, 846 
hemiplegic, 845 
infectious diseases and, 

845 
mental state in, 845 
ocular palsies in, 847 
paralysis in, 844, 845, 846 
pathology of, 849 
porencephaly in, 849 
position in, 846 
post-hemiplegic chorea in. 

848 
prognosis of, 849, 850 
reflexes in, 846 
sensibility in, 847 
symptoms of, 844, 845 
treatment of, 851 
trophic disturbances in, 
848 
Erb's, 857 

diagnosis of, 857 

from cerebral birth pal- 
sies, 857 
prognosis of, 857 
symptoms of, 857 
treatment of, 857 
facial, 851 

basilar disease of brain and, 

853 
caries of bone and, 852 
mastoid disease and, 851, 852 
operative, 853 
otitis and, 851 
symptoms of, 853, 854 
treatment of, 854 
infantile, epilepsy and, 820 
nuclear, facial expression in, 39 
obstetrical, 857. See Palsy, Erb's 
ocular, in infantile cerebral palsy, 
847 
Paludism, 334. See also Malarial fever 
Pancreas, ferments of, 498 

secretions of, 497 
Pancreatic secretion in newborn, 169 
Panophthalmitis in scarlet fever, 276 
Paradysentery, 528. See also Dysentery 



INDEX. 



<m 



Paralysis, acute atrophic, 861 

in acute encephalitis, 860, 861 

poliomyelitis, 868, 869 
in amaurotic idiocy, 838, 839 
Bell's, 851 
birth, 232 

position of head in, 38 
symptoms of, 232 
treatment of, 232 
in cerebrospinal meningitis, 353 
diagnosis of, from rachitis, 246 
diphtheritic, 391 

ataxic gait in, 50 
cardiac, 390 
patellar reflex in, 49 
position of head in, 38 
essential of children, 861 
facial, in tuberculous meningitis, 

435 
in hysteria, 804 
infantile, 861 

diagnosis of, from infantile 

cerebral palsy, 850 
limping gait in, 51 
in infantile cerebral palsy, 844 
Landry's, patellar reflex in, 49 
in multiple neuritis, 855 
ocular, in acute encephalitis, 861 
post-diphtheritic, 391 
pseudohypertrophic muscular, 873, 
875 
complications of, 875 
consanguinity and, 873 
diagnosis of, 875 

from congenital spas- 
tie paralysis, 875 
electrical reaction in, 875 
etiology of, 873 
gait in, 50, 874 
pathology of, 875 
prognosis of, 875 
reflexes in, 875 
sensation in, 875 
symptoms of, 874 
treatment of, 875 
varieties of, 875 
of soft palate in, 395 
traumatic, diagnosis of, from teta- 
nus of newborn, 216 
Paralytic form of idiocy, 878 
Paranephritis, 788 
Paraplegia, 843 

congenital spastic, diagnosis of, 
from pseudohypertrophic muscu- 
lar paralysis, 875 
hereditary ataxic, 858 
.spastic, spastic gait in, 51 
Parasites, intestinal, 555 

of liver, 567 
Paratyphlitis, 547 
Parathyroid gland in tetany, 809 
Parenchymatous nephritis, acute, 776 
Paresis, facial, in cerebrospinal menin- 
gitis, 353 
Parietal lobe, tumors of, 841 
59 



Parotid gland, secretion of, in new- 
born, 169 
Parotitis, enlargement of lymph-nodes 
in, 715 
epidemic, 368. See also Mumps 
facial expression in, 39 
infectious, diagnosis of, from acute 

adenitis, 716 
in typhoid fever, 326 
Pasteurization, comparison of, with 
sterilization, 107, 108 
of cows' milk, 106 
disadvantages of, 108 
effect of, on milk, 106 
in summer, 109 
in winter, 109, 110 
Pasteurizer, Freeman's, 106, 107 
Patellar reflex, 49 

in newborn, 175 
Pavor nocturnus, 821 

adenoids and, 822 
in chorea, 825 
epilepsy and, 822 
etiology of, 821 
hallucinations in, 822 
prognosis and, 822 
treatment of, 822 
Peliosis rheumatica, 466, 750 
Pemphigus neonatorum, 894 
etiology of, 895 
prognosis of, 895 
symptoms of, 894 
treatment of, 895 
Pepsin in newborn, 169 
Peptogenic milk powder, 112 
Peptone preparations, 116 
Peptonized milk, 112, 116, 154, 155 
Percentage method of artificial infant- 
feeding, 135, 136 
Percussion of chest, 43 

dulness in, normal, 612 
Perforating empyema, 664 
Perforative acute appendicitis, 548 

peritonitis, 569 
Perforation of drum in otitis, 761 
Pericarditis, 674 

abdominal pain in, 45 
apex-beat in, 676 
auscultation in, 678 
bacteriology and, 674 
bronchopneumonia and, 642 
in chorea, 826 

in congenitally weak infants, 184 
diagnosis of, 679 

from pleural effusions, 679 
dyspnoea in, 676 
effusion in, 676, 677 
endocarditis and, 692 
etiology of, 674 
exanthemata and, 674 
facies in, 676 
forms of, 674 

fibrinous, 674 
purulent. 674 
tuberculous, 675 
friction-sound in, 678 



930 



INDEX. 



Pericarditis, inspection in, 676 
lobar pneumonia and, 628 
in measles, 303 
myocarditis in, 675 
occurrence of, 674 
orthopncea in, 676 
palpation in, 676 
pathology of, 675 
percussion in, 677 
physical signs of, 676 
pleuropericardial friction-sounds in, 

679 
pleuropneumonia and, 674 
prognosis of, 680 
puncture of pericardium in, 680 
rheumatism and, 674 
in scarlet fever, 276, 279 
in sepsis in newborn, 204 
symptoms of, 675 
treatment of, 680 
tuberculosis and, 674 
Pericardium, adherent, 681 
etiology of, 681 
myocarditis and, 681 
symptoms of, 681 
diseases of, 674 

puncture of, in pericarditis, 680 
tuberculosis of, 432 
Perifolliculitis abscedens, 891 
Perinephritis, 788 
etiology of, 788 
pyelonephritis and, 788 
scarlet fever and, 788 
symptoms of, 788 
treatment of, 788 
Periodic vomiting, 503 
Peri-cesophageal abscess, 491 
Periostitis, hemorrhagic, 254 
Peristalsis in pyloric spasm, 514 
Peritoneal cavity, cysts of, diagnosis of, 
from acitis, 568 
tumors of, diagnosis of, from 
ascitis, 568 
Peritoneum, diseases of, 567 

tuberculosis of, 426 
Peritonism, 571 
Peritonitis, acute, 568 

acquired constipation and, 536 
bacteriology of, 568, 569 
bacterium coli communis in, 

569 
blood in, 570 
constipation in, 569 
diagnosis of, 570 

from typhoid fever, 570 
etiology of, 568 
onset of, 569 
pain in, 569 
prognosis of, 570 
symptoms of, 569 
vomiting in, 569 
gonococcal, 570 

diagnosis of, 571 

from appendicitis, 571 
etiology of, 571 
prognosis of, 571 



Peritonitis, gonococcal, symptoms of, 
571 

treatment of, 571 
ascaris lumbrieoides and, 569 
chronic simple, 573 
colic in, 509 
in dysentery, 532 
of newborn, 214 
non-tuberculous, diagnosis of, from 

tuberculosis of peritoneum, 429 
perforative, 569 
in phlebitis umbilicalis, 211 
pneumococcal, 572 

diagnosis of, 572 

from appendicitis, 572 
from tuberculosis of peri- 
toneum, 572 

etiology of, 572 

primary, 572 

prognosis of, 572 

secondary, 572 

symptoms of, 572 

umbilicus in, 572 
pneumococci in, 569 
septic, retracted, abdomen in, 44 
simple chronic, 573 
tuberculous, 426 

acute, 569 

diagnosis of, from acute ap- 
pendicitis, 550 

rectal exploration in, 46 
tympanites in, 44 
vulvovaginitis and, 791 
Perityphlitis, 547 
Perleche, 475 
Permanent teeth, 471 
Pernicious anaemia, 752 
Persistent bronchopneumonia, 648 

tetany, 812 
Pertussis, bronchopneumonia and, 638 
convulsiva, 372 

bacteriology of, 373 

blood in, 375 

bronchitis and, 375 

bronchopneumonia and, 375 

cardiac dilatation in, 375 

catarrhal stage of, 374 

convulsions in, 376 

diagnosis of, 376 

diphtheria and, 393 

etiology of, 373 

gastro-enteritis in, 376 

hemorrhages in, 376 

incubation of, 373 

kidneys in, 375 

melancholia and, 376 

pathology of, 373 

pneumonia and, 375 

prognosis of, 377 

prophylaxis of, 377 

psychoses in, 376 

spasmodic stage of, 374 

symptoms of, 374 

treatment of, 377 

tuberculosis and, 376 
in measles. 305 
myocarditis and, 708 



INDEX. 



931 



Petechial fever, 347 
Petit mal, 820 - 
Phantom tumor of liver, 562 
Pharyngeal tonsil, hypertrophiecl, 580 
Phlebitis umbilicalis, 210 

abscesses, metastatic in, 211 
jaundice in, 21] 
meningitis in, 211 
peritonitis in, 211 
pleuritis in, 211 
pyaemia in, 211 
treatment of, 211 
Phlegmon of scalp, diagnosis of, from ^ 
cephalhematoma, 235 
of umbilicus, 208 
Phlegmonous laryngitis, 594 
Phosphorus in cows' milk, 103 
Photophobia, 40 

in measles, 296, 304 
Physical development, 34, 35, 36 
Pica, 805 

treatment of, 806 
Pin-worm, 557 
Plasmodium malaria?, 334 
Plastic bronchitis, 600 
Pleasure, feelings of, development of, 

35 
Pleura, diseases of, 650 
tuberculosis of, 432 
Pleural fold, displacement of, in em- 
pyema, 661 
Pleurisy, 650 

abdominal pain in, 45 
bronchiectasis and, 607, 609 
bronchophony in, 662 
dry, 650 

diagnosis of, 651 
etiology of, 651 
pain in, 651 
prognosis of, 651 
symptoms of, 651 
treatment of, 652 
hemorrhagic, 672 
lobar pneumonia and, 627 
metapneumonic, 657 
purulent, 652 

subacute, 652. See also Empyema 
suppurative, 652 
with effusion, 650, 652 
Pleuritis, 650 

diphtheria and, 388 
in phlebitis umbilicalis, 211 
in scarlet fever, 280 
Pleuropericardial friction-sounds in per- 
icarditis, 679 
Pleuropneumonia, pericarditis and, 674 
Pneumococcal peritonitis, 572 
Pneumoeocci in peritonitis, 569 
Pneumococcus of Friinkel in broncho- 
pneumonia, 633 
Pneumonia, abdominal pain in, 45 
acetone in urine in, 33 
acute infectious osteomyelitis and, 

757 
bronchiectasis and, 607, 009 
catarrhal, 632 



Pneumonia, colic in, 509 
croupous, 615 
cystitis and, 793 

diagnosis of, from cerebrospinal 
meningitis, 359 



from typhoid fever, 



iO 



endocarditis and, 690 
fibrinous, 615 

bronchitis and, 600 
full bath in, 65 
gavage in, 71 
hemorrhagic, in congenitally weak 

infants, 184 
in influenza, 342 
Kernig's symptom in, 50 
lobar, 615 

age and, 615 

bacteriology of, 617 

blood in, 623 

bradycardia in, 621 

chills in, 622 

complications of, 626 

cough in, 618, 622 

crisis in, 618 

delirium in, 622 

diagnosis of, 629 

from acute appendicitis, 

551 
from bronchopneumonia, 

645 
from influenza, 629 
from meningitis, 629 
from typhoid fever, 629 

dyspnoea in, 618, 622 

empyema and, 627, 628, 652 

etiology of, 617 

gray hepatization in, 616 

hydrotherapy in, 630 

hygiene in, 632 

induration of lung in, 617 

in influenza, 341 

leucocytosis in, 623 

melancholia in, 623 

meningitis and, 627 

occurrence of, 615 

onset of, 618 

opisthotonos in, 623 

otitis and, 626 

pain in, 618 

pathology of, 616 

pericarditis and, 628 

physical signs of. 023 

pleurisy and. 627 

prognosis of, 628 

rale, crepitant in. 624 
redux in, 625 

sex and, 615 

of short duration. 625 

situation of, 615 

stages of. 021. 625 

symptoms of, 617 

temperature in. 619, 020. 021 

treatment of. 030 

tympanites in, 631 
lobular, 632 
lumbar puncture in. 78 



932 



INDEX. 



Pneumonia in measles, 301, 302 
mumps and, 371 
otitis and, 761 
myocarditis and, 708 
pertussis convulsiva and, 375 
in scarlet fever, 280 
in scleredema, 225 
in sepsis in newborn, 201, 206 
tympanites in, 45 
in typhoid fever, 326, 328 
in varicella, 313 
Pneumonic fever, 615 
Poisoning, stomach washing in, 70 
Polioencephalitis, acute, 859 
Poliomyelitis, acute, 861 
atrophy in, 870 
bone in, retardation of growth 

of, 870 
brain in, 863 
diagnosis of, 871 

from cerebral palsy, 871 
from cerebrospinal menin- 
gitis, 871 
from multiple neuritis, 871 
forms of, 864, 865 
abortive, 867 
ataxic, 867 
bulbar, 865 
cerebral, 867 
encephalitic, 867 
polyneuritic, 867 
pontine, 865 

simulating Landry 's pa- 
ralysis, 865 
paralysis in, 868, 869 
pathology of, 862 
prognosis of, 871 
sequelae of, 872 
symptoms of, 864 
treatment of, 872 
anterior. See Poliomyelitis, acute 
epidemic. See Poliomyelitis, acute 
muscular atrophy in, 49 
patellar reflex in, 49 
Polyarthritis rheumatica, 459 
Polycythaemia, 734 
Polydipsia in diabetes mellitus, 712 
Polypoid tumors of umbilicus, 207 
Polypus of rectum, 554 
Polyuria, 712 
Pons, tumors of, 842 
Porencephaly in infantile cerebral palsy, 

849 
Post-diphtheritic paralysis, 391 
Post-hemiplegic chorea in infantile cer- 
ebral palsy, 848 
convulsions, diagnosis of, from epi- 
lepsy, 821 
Postural albuminuria, 770 
Potain's aspirator for empyema, 667 
Pott's disease, position of head in, 38 

spine in, 47 
Pregnar 'y, effect of, on human milk, 99 
Premature birth, 19 
infants, 183 

temperature in, 30 



Proctitis, 554 

gonorrhoeal, 554 
treatment of, 554 
Productive nephritis, acute, 776 

chronic, 781 
Progressive aneemia in uncinariasis 

muscular atrophy. Erb's type of, 
872 
Prolapsus ani, 552 

etiology of, 552 
symptoms of, 553 
treatment of, 553 
Proteids. in artificial infant-feeding, 
137 
in artificial infant foods, 121 
calories in, 87 
in cows' milk, 103 
estimation of, in human milk, 102 
estimation of, Woodward's method 

of, 102 
in human milk, 92 
low percentage of, 154 
ratio of, in food, 86 
role of, in nutrition, 83, 84 
variation of, in cows' milk, 148 
Pruritus in diabetes mellitus, 712 
Pseudochorea, 822 
Pseudocroup, 593 
Pseudodiphtheria, 410 

in scarlet fever, 270 
Pseudodiphtheritic stomatitis, 482 
Pseudohypertrophic muscular paralysis, 

873 
Pseudoleukaemia, 747 
Pseudoleukaemic angemia, 739 
Pseudo-masturbation, 807 
Pseudomembranous deposits in sepsis in 
newborn, 203, 205 
rhinitis, 578 
Psoas spasm, 48 
Psychic hysteria, 802 
Ptosis in typhoid, fever, 328 
Puerile breathing, 613 

tetany, 813 
Pulmonary artery in congenital disease 
of heart, 686 
stenosis of, 687 
blood in, 688 
clubbed fingers in, 688 
cyanosis in, 688 
murmur in, 688 
physical signs of, 688 
ventricular hypertrophy 
of, 688 
dyspnoea, 614 
resonance, normal, 611 
tuberculosis, 421 
Pulse, arrhythmia of, 30 
dicrotism of, 30 
irregularity of, 30 
in newborn, 168 
rapidity of, 29 
rhythm of, 30 
Pulse-respiration ratio in infants, 29 
Puncture, lumbar. See also Lumbar 
puncture 



INDEX. 



Puro, 115 

Purpura hemorrhagica, 749 

diagnosis of various forms of, 

750, 751, 752 
etiology of, 750 
hemorrhages in, 749 
prognosis of, 750 
symptoms of, 749 
treatment of, 750 
Henoch's, 751 
rheumatica, 750 

etiology of, 750 
prognosis of, 751 
symptoms of, 751 
treatment of, 751 
simple, 748 

etiology of, 748 
petechia? in, 748 
prognosis of, 748 
symptoms of, 748 
treatment of, 748 
Purulent otitis media, 759, 760 
pericarditis, 674 
pleurisy, 652 
Pustular eczema, 885 
Putrid bronchitis, 606 
Pyaemia in phlebitis umbilicalis, 211 
Pyelitis, 793. See also Cystitis 
Pyloric spasm, congenital, 511 
enemata in, 517 
gavage in, 517 
treatment of, operative, 517 
stenosis, 511 

congenital hypertrophic, 511 
constipation in, 513 
diagnosis of, 515 
etiology of, 512 
feeding in, 516 
pathology of, 512 
peristalsis in, 514 
prognosis of, 516 
symptoms of, 513 
treatment of, 516 
vomiting in, 507, 513 
Pylorus and stomach-wall, congenital 

hypertrophy of, 512 
Pyelonephritis, 793. See also Cystitis 

perinephritis and, 788 
Pyopneumothorax, 664 
subphrenicus, 672 
symptoms of, 664 
Pyuria in typhoid fever, 328 



Quantitative estimation of fats, Soxh- 

let 's, 101 
Quevenne's lactodensimeter, 100 
Quincke funnel, SO 
needle, 77 

R 

Rachischisis, 879 

cystica, 8S0 
Rachitis, 237 

acute, 254. See Scorbutus, infantile 



Rachitis, acute, simple bronchitis and, 
597 
anaemia in, 245 
blood in, 245, 246, 735 
" bow-leg " deformity in, 244 
brain in, 240 

from condensed milk, 113 
congenital, 237 
craniotabes in, 237, 240, 245 
definition of, 237 

delay of closure of f ontanelles in, 27 
dentition in, 471 
diagnosis of, 246 

from congenital internal hy- 
drocephalus, 834 

from cretinism, 246 

from Mongolian idiocy, 246 

from osteogenesis imperfecta, 
253 

from paralysis, 246 

from syphilis, 246 
duration of, 245 
emphysema of lungs and, 602 
enlargement of lymph-nodes in, 716 
facial expression in, 39 
foetal, 237 
fontanelles in, 240 
head in, 240 
hemorrhagic, 237, 254 
hydrocephalus in, 240, 245 
hydrochloric acid and, 238 
infantile scorbutus and, 255 
intestinal disturbances in, 244 
intra-uterine, 237 
lactic acid and, 238 
laryngismus stridulus and, 817 
leukaemia and, 743 
lime salts and, 238 
liver in, 239, 245 
lymph-nodes in, 239 
nervous system in, 245 
nystagmus in, 40 
osteoid tissue in, 238, 239 
pain in, 242 
pathology of, 238 
pelvis in, deformity of, 243 
prognosis of, 247 
pseudoleukaemic anaemia and. 741 
race and, 237 
respiration in, 241 
rhythmic movements of head and 

nystagmus and, 832 
" sabre' ' deformity in, 244 
severity of, 245 
sex and, 237 
shape of head and. 38 
simple, enlargement of liver in. 562 
spinal curvatures in. 243 
spine in, 47 

deformity of, 243 
spleen in, 239, _ L5 
status lymphaticus and. 729 
syphilis and, 23S 
tarda. 246 
theories o\\ 238 
thorax in. deformity oi. 240 



934 



INDEX. 



Rachitis, treatment of, 247 

tympanites in, 45 
Rale, crepitant in lobar pneumonia, 624 

redux in lobar pneumonia, 625 
Rash in scarlet fever, 272 

wandering of tongue, 486 
Raw milk, 109 
Rectal enema, 72 

excreta in newborn, 174 
feeding, contra-indications for, 164 
temperature in newborn, 170 
table of, 31 
Rectum, adenomata of, 554 
anatomy of, 552 
exploration of, 46 
in abscess, 46 
in intussusception, 46 
in tuberculous peritonitis, 46 
irrigation of, 72 
polypus of, 554 
age and, 554 
diagnosis of, 555 
location of, 554 
prognosis of, 555 
symptoms of, 555 
treatment of, 555 
position of, 552 
Red blood-cells, 734 
Reflex, Babinski's, 49 

in tuberculous meningitis, 49 
patellar, 49 
Renal calculi, 775 

etiology of, 776 
symptoms of, 776 
treatment of, 776 
Resiliency of chest -wall, 611 
Resonance, pulmonary, normal, 611 

tympanitic, normal, 613 
Respiration, artificial, 195 

in asphyxia in the newborn, 

195, 196 
methods of, 195, 196 
Dew, 196 

mouth-to-mouth, 196 
Schultze, 195, 196 
character of, 28 
cnemism of, 28 
diaphragmatic, 28 
excretion of carbon dioxide in, 28 
in newborn, 165 
normal frequency of, 28 
Respiratory diseases, sudden death in, 
20 
disorders, facial expression in, 39 
disturbances in childhood, 17, 18 
system, diseases of, 574 
Retentio testis, 182 
Retinitis in scarlet fever, 279 
Retro -oesophageal abscess, 491 
Retropharyngeal abscess, 585 

lymphadenitis, 585 
Revaccination, 318 

Rheumatic cases of follicular amygda- 
litis, 590 
fever, 459 
form of facial palsy, 851 



Rheumatic nodules, subcutaneous, 466 
Rheumatism, acute articular, 459 
age and, 460 
chorea in, 462 
endocarditis and, 690 
endocarditis in, 461 
etiology of, 459 
heredity and, 460 
prognosis of, 462 
sex and, 460 
symptoms of, 460 
treatment of, 462 
types of, 461 
chorea and, 823, 824 
endocarditis and, 693 
gonorrhoeal, 466 
muscular, 467 
pericarditis and, 674 
scarlatinal, 277 
Rheumatoid arthritis, 463 
Rhinitis, adenoid growths and, 580 
diphtheritic, 578 

Klebs-Loffler bacillus in, 578 
streptococcic form of, 578 
symptoms of, 578 
treatment of, 578 
pseudomembranous, 578 
Rhinorrhagia, 579 
Rhythm of pulse, 30 
Rickets, 237 

foetal, 250 
Ridge's food, 121 
Rigidity of spine, tests for, 48 
Ringworm of tongue, 486 
Robinson's groats, 121 

patent barley, 114, 121, 158 
Rocking, evil effects of, 59 
Roger's disease, 689 
Roseola, syphilitic, diagnosis of, from 
measles, 307 
Trousseau's, 291. See Rotheln 
in typhoid fever, 322 

diagnosis of, from measles, 307 
Rotch's method of artificial infant- 
feeding, 133, 135 
Rotheln, 291 

complications of, 293 
desquamation in, 292 
diagnosis of, from measles, 306 

from scarlet fever, 282, 293 
eruption in, 292 
exanthema in, 291 
genitals in, 293 
lymph-nodes in, 292 
mucous membranes in, 292 
prodromal period of, 291 
prognosis of, 293 
spleen in, 293 
symptoms of, 291 
treatment of, 293 
Round worms, 556 

symptoms of, 556 
treatment for, 55<3 
Rubella, 291. See Rotheln 
Rubeola, 294. See Measles 



INDEX. 



"Sabre" deformity in rachitis, 244 
St. Vitus' Dance, 822, See also Chorea 
Salicylic acid in human milk, 97 
Saliva in newborn, 169 
Salt solution, Cantani's, 66 

in artificial infant-feeding, 137 
mineral, 83 

in human milk, 93 
Sarcoma of kidney, 785 

of thymus gland, 729 
Savory and Moore's food, 120 
Scalp, seborrhcea of, 886 
Scarlatinal rheumatism, 277 
Scarlet fever, 265 

abscess of brain in, 275 
of skin in, 272 

acute infectious osteomyelitis 
and, 757 
nephritis and, 776 

albumin in, 282 

albuminuria in, 278 

amaurosis in, 279 

anaemia and, 280 

angina in, 267, 270 
membranous, 270 

aphasia in, 279 

arthritis and, 277 

bacteriology of, 284 

blood in, 280 

bronchopneumonia and, 639 

cardiac hypertrophy in, 280 

chorea and, 281 

conjunctivitis in, 276 

contagion in, zone of, 266 

convulsions in, 279 

cystitis and, 793 

deafness in, 275 

desquamation in, 273 
duration of, 274 

diagnosis of, 281 

from drug eruption, 282 
from measles, 282, 306 
from rotheln, 282, 293 

diarrhoea in, 280 

diphtheria in, 270 

diphtheroid in, 270 

disinfection and, 285 

ear in, 275 

eclampsia in, 279 

empyema in, 276 

enanthema in, 281 

endocarditis in, 279, 690 

eruption in, 271 

etiology of, 265 

exanthema in, 271 

eye in, 276 

fever in, 273 

from infected cows' milk, 105 

full bath in, 65 

gangrene in, 272 
of lung in, 280 

glandular swellings and, 280 

heart in, 279 

immunity to, 267 



Scarlet fever, incubation of, 267, 268 

intestine in, 280 

joints in, 277, 290 

kidneys in, 277 

leucocytosis in, 280 

lungs in, 280 

lymph-nodes in, 270, 273, 276 

mania in, 279 

mastoid disease and, 273, 766 

melancholia in, 279 

meningitis in, 275 

mouth in, 271, 277 

myocarditis in, 279 

nephritis in, 277, 278, 289 

nose in, 274, 287 

otitis in, 273, 290 

panophthalmitis in, 276 

pathology of, 283 

pericarditis in, 276, 279 

perinephritis and, 788 

pleura in, 280 

pleuritis in, 280 

pneumonia in, 280 

prognosis of, 282 

prophylaxis of, 285 

pseudodiphtheria in, 270 

psychoses and, 281 

rash in, 272 

relapses in, 281 

retinitis in, 279 

retropharyngeal abscess in, 
271, 276 
adenitis in, 276 

second attacks of, 281 

sequelae of, 280 

sinus thrombosis in, 275 

skin in, 272, 283 

stomach in, 280 

stomatitis in, 277 

strawberry tongue in, 271 

streptococcsemia in, 271 

surgical, 270 

susceptibility to, 266 

symptomatology of, 267 

temperature in, 269 

tongue in, 271 

tonsillitis in, 271 

treatment of, 286 

tuberculosis and, 280 

uraemia in, 273, 279 

urine in, 278 

wound infection with, 270 
Schonlein's disease, 750 
Schultze method of artificial respira- 
tion, 195, 196 
Sclerema adiposum, 226 

diagnosis of, from oedema of 
nephritis, 227 
from sclercedema. 2i!7 

pathology of, 227 

prognosis of, 228 

skin in, 227 

symptoms of. 226 

treatment o\\ 228 
in congenitallv weak infants. 1S4 
fat-, 226 



936 



INDEX. 



Sclerema neonatorum, 224 

in newborn, 224 
Scleredema, complications of, 225 

diagnosis of, from sclerema adipo- 

sum, 227 
etiology of, 224 
neonatorum, 224 
pathology of, 226 
pneumonia in, 225 
prognosis of, 226 
symptoms of, 224 
treatment of, 226 
Sclerosis, multiple, patellar reflex in, 49 
Sclerotic form of idiocy, 878 
Scoliosis, restriction of movements of 

chest in, 611 
Scorbutus, infantile, 254 
bones in, 256 

fracture of, 256, 258 
deformities in, 257 
diagnosis of, 259 

from syphilis, 259 
from acute infectious os- 
teomyelitis, 758 
diet and, 255 
duration of, 259 
ecchymoses in, 257 
etiology of, 254 
gums in, 257 
hematuria in, 256, 257 
hemorrhages in, 256, 257, 258 

intestinal, 259 
joints in, 257 
pain in, 257 
paralysis in, 257 
pathology of, 256 
prognosis of, 259 
pulse in, 258 
rachitis and, 255 
symptoms of, 256 
treatment of, 259 
urine in, 251 
Scott's oat flour, 121 
Scrofulosis, 411 

bones in, 412, 415 
cornea in, 412 
diagnosis of, 416 
ears in, 414 
ecthyma in, 413 
eczema in, 413 
etiology of, 411 
eye in, 414 
joints in, 412, 415 
lichen scrofulosorum in, 413 
lupus in, 413 
lymph-nodes in, 412, 414 
mucous membranes in, 413 
otitis in, 414 
ozena in, 413 
pathology of, 412 
prognosis of, 416 
skin in, 412, 413 
symptoms of, 413 
treatment of, 416 
tubercle bacillus and, 412 
Scrotum, anomalies of, congenital, 181 



Scurvy, diagnosis of, from intussuscep- 
tion, 545 

infantile, 254 

in marantic infants, 159 

rickets, 254 

from sterilized milk, 108 
Seborrhea capillitii, 886 

of scalp, 886 

treatment of, 890 

of umbilicus, 886 
Seborrheic eczema, 886 
Sepsis in congenitally weak infants, 184 

endocarditis and, 690 

neonatorum, 201 

in newborn, 201 
icterus in, 217 
Septic endocarditis, 696 

infections, true omphalorrhagia in, 
212 
Septum, auricular, congenital defects 
of, 689 

ventricular, congenital defects of, 
689 
Sight, development of, 35 

examination of, 40 
Sinus thrombosis in scarlet fever, 275 
Sitting, development of, 35 
Skin, care of, 61, 884 

in congenitally weak infants, 184 

in diabetes mellitus, 712 

diphtheria of, 392 

diseases of, 884 

eruptions of, 884 

examination of, 38, 884 

in newborn, 170 

desquamation of, 884 

edema of, 884 

reflex in newborn, 175 

in scarlet fever, 272 

in sepsis in newborn, 202 
Skodaic resonance in empyema, 659 
Skull, deformities of, 879 
Sleep, 58 

normal facial expression in, 39 

in open air, 63 

rapidity of pulse during, 30 

temperature during, 30 
Smell, sense of, in newborn, 176 
Solitary tubercle of brain, 443 
Somatose, 116 
Sore throat, traumatic, diagnosis of, 

from diphtheria, 396 
Soxhlet method of artificial infant- 
feeding, 135 
Soxhlet 's quantitative estimation of 

fats, 101 
Spasm of anus, 554 

congenital pyloric, 511 

of glottis, 816 

habit, 831 

nystagmus in, 40 

psoas, 48 
Spasmodic croup, 593 

laryngitis, 593 
Spasmophiles. See status lymphaticus 

latent tetany, 730, 812 



INDEX. 



937 



Spasmus nutans, 832 
Spastic, gait, 51 

hemiplegia, 843, 845 
Speech, development of, 36 
Spina bifida, 880 

deformities of foot in, 882 
diagnosis of, 882 
occulta, 883 
symptoms of, 881 
treatment of, 881 
tumor in, 881 
Spinal curvatures in rachitis, 293 
canal, deformities of, 879 

introduction of drugs into, 80 
of serum into, 80 
Spine, anatomy of, 47 
deformity of, 47 
examination of, 47 
in meningitis, 48 
painful areas in, 47 
in Pott's disease, 47 
in rachitis, 47 
rigidity of, 47, 48 
Spitting in bottle-fed infants, 152 
in breast-fed infants, 152 
treatment of, 152 
Splenic puncture in sepsis in newborn, 
205 
tumor in fibrinous bronchitis, 601 
Spleen, anatomy of, 732 
diseases of, 732 
enlargement of, 733 
in leukaemia, 744 
in pseudoleukaemic anaemia, 740 
examination of, 732, 733 
palpation of, 733 
percussion of, 732 
in rachitis, 239, 245 
in rotheln, 293 
size of, 732 
tumor of, 734 

diagnosis of, from tumor of 
kidney, 734 
Sponge bath, 64, 65 
Sporadic cretinism, 719 
Spotted fever, 347. See Meningitis, 

cerebrospinal 
Spray, vapor, 68 
Sprue, 61, 62, 476 
etiology of, 477 
occurrence of, 477 
symptoms of, 477 
treatment of, 478 
Standing, development of, 35 
Staphylococcus albus in human milk, 94 
Starch, digestion of, in newborn, 169 
Status epilepticus,' lumbar puncture in, 
77 
lymphaticus, 729 

Chvostek's symptom in, 730 
rachitis and, 729 
symptoms of, 730 
treatment of, 731, 732 
Trousseau's phenomenon in, 
730 
praesens, expression in, 3S 



Status praesens, posture in, 38 

taking of, 38 
Stearin, 84 
Stenosis of aortic valve, 686 

pulmonary artery, 687 
Sterilization, comparison of, with pas- 
teurization, 107, 108 
of cows' milk, 107 
disadvantages of, 107, 108 
effect of, on milk, 107 
in summer, 110 
Sterilizer, Arnold's, 107 
Sternomastoid muscle, haematoma of, 

.233 
Stethoscope, 41, 42 

binaural, 42 
Still's disease, 463, 465 

enlargement of liver in, 563 
etiology of, 465 
symptoms of, 465 
Stomach, acids of, 495 
anatomy of, 494 
bacterial flora in, 497 
capacity of, 494 
contents, examination of, 37 
digestion in, 496 
dilatation of, 509 
etiology of, 509 
physical signs of, 511 
prognosis of, 511 
symptoms of, 510 
treatment of, 511 
vomiting in, 510 
diseases of, 493 
function of, 494 
lab-ferment in, 496 
milk sugar in, 497 
motility of, 494 
percussion of, 494 
position of, 494 
ulcer of, 511 
washing of, 69 

indications for, 69 
in poisoning, 70 
in vomiting, chronic dvspeptic, 
69 
persistent, 69 
Stomatitis, 61, 62 
aphthous, 478 

bacteriology of. 479 
etiology of, 479 
symptoms of, 479 
treatment of, 480 
diagnosis of, from diphtheria. 394 
in measles, 305 
pscudodiphtheritic, 4S2 
symptoms of, 4 Si! 
treatment of, 483 
in scarlet fever, 277 
toxic, 4S0 

symptoms ot\ 4>0 
treatment of. 4 SO 
ulcerative, ISO 

etiology of. 4 SO 
symptoms o\. 481 
treatment o\. 4S1 



938 



INDEX. 



Stools, normal, 499 

bacterial flora in, 501 
in bottle-fed infants, 499 
in breast-fed infants, 499 
composition of, 500 
number of, daily, 501 
reaction of, 500 
variation of, in breast-feeding, 130, 
131 
Streptococcaemia in scarlet fever, 271 
Streptococcic form of diphtheritic rhi- 
nitis, 578 
Stricture, congenital, of oesophagus, 489 

traumatic, of oesophagus, 490 
Stridor, congenital, of infants, 815 
etiology of, 816 
larynx in, 816 
respiration in, 816 
symptoms of, 815, 816 
laryngeal, 816 
Subacute pleurisy, 652 
Subcutaneous tuberculin test, 425 
Submaxillary gland, secretion of, in 

newborn, 169 
Subphrenic abscess, 672 
Sudamina, 61, 892 

Sugar, in artificial infant-feeding, 137 
in cows' milk, 102 
grape, 85 
milk, 85 
Summer diarrhoea, 517 
Sunburn, 60 

Suppurating sinus, persistent, in em- 
pyema, 670 
Suppurative acute appendicitis, 548 
hepatitis, 566 
pleurisy, 652 
Suprarenal bodies, diseases of, 753 
Sydenham's chorea, 822 
Symptomatic chorea, 822 
Syphilis, 444 

acquired, 444 

diagnosis of, 444 

from hereditary syphilis, 
445 
infection with, mode of, 444 
prognosis of, 444 
symptoms of, 444 
acute simple bronchitis and, 597 
of bones, 756 

of skull, 756 
bronchiectasis and, 607 
congenital, 448 

facial expression in, 40 
of nose, 574 

diagnosis of, from acute infec- 
tious osteomyelitis, 758 
enlargement of liver in, 563 
of lymph-nodes in, 715 
true omphalorrhagia in, 212 
congenitally weak infants and, 184 
contra-indication to maternal nurs- 
ing, 123 
cranial, diagnosis of, from congen- 
ital internal hydrocephalus, 836 
dental amorphism in, 473 



Syphilis, dental, infantilism in, 473 
dentition in, 470 

diagnosis of, from osteogenesis im- 
perfecta, 253 
from rachitis, 246 
fissure of anus in, 553 
hereditaria tarda, 445 
hereditary, 448 
bones in, 451 
Colles 's law in, 448 
dactylitis syphilitica in, 455 
diagnosis of, 456 
etiology, 448 

glandular apparatus in, 451 
Hochsinger 's induration in, 

453 
kidneys in, 450 
hereditary, late, 445 

bones in, 446 
ear in, 447 
eyes in, 446 
liver in, 448 
lymph-nodes in, 447 
psychoses in, 448 
skin in, 447 
spleen in, 448 
symptoms of, 445 
liver in, 450 
lungs in, 450 
osteochondritis in, 454 
pancreas in, 451 
pathology of, 449 
prognosis of, 457 
spleen in, 450 
symptoms of, 451 
treatment of, 458 
Hutchinson's teeth in, 471 
of larynx, 596 
leukaemia and, 743 
of liver, 565 
microdontism in, 473 
rachitis and, 238 
roseola, diagnosis of, from measles, 

307 
of thymus gland, 729 
Syphilitic adenopathy, 715 

form of idiocy, 878 
Syringing of nose, 66 
Syringomyelocele, 881 



Tabes, diagnosis of, from hereditary 
ataxia, 859 
mesenterica, 431 
Tache cerebrale in acute encephalitis, 
860 
in cerebrospinal meningitis, 
352, 359 
Tachycardia in hysteria, 804 
Taenia elliptica, 557 

mediocanellata, 557 
solium, 557 
Tapeworm, 555, 557 
symptoms of, 558 
treatment for, 558 



INDEX. 



939 



Tarnier's incubator, 186 
Taste, development of, 35 

sense of, in newborn, 176 
Tay-Kingdon's spot in amaurotic idiocy, 

839 
Tea, effect of, on human milk, 97 
Teeth, eruption of, care of mouth after, 

62 

Hutchinson's, 471 

milk, 470 
permanent, 471 
temporary, 470 
Temperature in bottle-fed children, 30 
in breast-fed children, 30 
in congenitally weak infants, 185, 

186 
fluctuations of, daily, 30 
high, 63 

in newborn, 170 
in premature infants, 30 
rectal in newborn, 170 

table of, 31 
reduction of, 64 
rise of, during crying, 30 
during exercise, 30 
during excitement, 30 
during sleep, 30 
taking of, 56, 57 
axillary, 56 
frequency of, 57 
positions for, 56 
rectal, 56, 57 
variations of, normal, 30 
Temporary teeth, 470 
Temporosphenoidal lobe, tumors of, 842 
Tenesmus in intussusception, 544 
Testes, metastasis of mumps to, 371 
Testicle, retention of, 182 
abdominal, 182 
diagnosis of, 182 

from hernia, 182 
double, 182 
iliac, 182 
inguinal, 182 
single, 182 
treatment of, 182 
Tetanilla, 808 
Tetanus antitoxin, 217 
human milk and, 98 
of newborn, 214 

antitoxin in, 217 
diagnosis of, 216 

from cerebrospinal menin- 
gitis, 216 
from traumatic paralysis, 
216 
etiology of, 214 
lumbar puncture in, 217 
pathology of, 215 
prognosis of, 216 
symptoms of, 215 
treatment of, 216 
vaccination and, 317 
Tetany, 808 

Ohvostek's symptom in, Sll 
diagnosis of, 8 L2 



Tetany, diagnosis of, from convulsions 
in infancy, 801 
etiology of, 808 

extremities in, position of, 810 
face in, 811 
forms of, 812 
laryngospasm and, 812 
late, 813 
latent, 812 
mortality of, 813 
muscular contractures in, 810 
parathyroid gland in, 809 
pathology of, 809 
prognosis of, 813 
puerile, 813 
sudden death in, 22 
symptoms of, 810 
treatment of, 813 
Trousseau's phenomenon in, 811 
Thermometer, disinfection of, 56, 57 
Thread-worm, 557 
Thrush, 476. See Sprue 
Thumb sucking, 806 

mental weakness and, 806 
Thymic asthma, 729 
Thymus death, 729, 730, 731 

hypertrophy of thymus gland 

in, 731 
lymphatism and, 729 
treatment of, 731 
enlargement of, in laryngismus 

stridulus, 817 
gland, abnormalities of, 728 
abscess of, 729 
carcinoma of, 729 
diphtheria and, 729 
diseases of, 728 
hemorrhages into, 729 
hypertrophy of, 728 

thymus death in, 731 
inflammation of, 729 
landmarks of, 728 
lymphatism and, 729 
percussion of, 728 
sarcoma of, 729 
syphilis of, 729 
tuberculosis of, 729 
weight of, 728 
Thyroid extract in treatment of cretin- 
ism, 725 
gland, cystic growths of. 71 S 
diseases of, 718 
enlargement of, 718 
Tic, 831 

convulsif, diagnosis of. from chorea, 

828 
coprolalia in. 833 
diagnosis of, from chorea. 831 
echolalia in. 831 
Titubation, cerebral. 50 
Tongue, congenital anomalies of. 4S4 
desquamation o\', 487 
diseases of. 'SI 
geographical, 486 
ringworm of. 486 
etiology of, 486 



940 



INDEX. 



Tongue, ringworm of, symptoms of, 486 
treatment of, 487 
in scarlet fever, 271 
strawberry, in scarlet fever, 271 
wandering rash of, 486 
Tongue-swallowing, 487 

treatment of, 487 
Tongue-tie, 487 

treatment of, 487 
Tonsillitis, catarrhal, 589 
endocarditis and, 466 
joint-pains and, 466 
in scarlet fever, 271 
ulceromembranous, 591 
diagnosis of, 592 

from diphtheritic ulcers, 
592 
etiology of, 592 
prognosis oi, 592 
symptoms of, 592 
treatment of, 592 
ulcer in, color of, 591 

size of, 591 
Vincent 's bacillus in, 592 
Tonsils, anatomy of, 588 
diseases of, 588 
enlarged, in emphysema of lungs, 

602 
in follicular amygdalitis, 589 
herpes of, 591 

infection of, enlargement of lymph- 
nodes in, 715 
Top milk, 141 

Torticollis, position of head in, 38 
Touch sense in newborn, 176 
Toxic myocarditis, 707 

stomatitis, 480 
Toxins of diphtheria, 380 
in endocarditis, 691 
in human milk, 97, 98 
Trismus neonatorum, 214 
Trousseau 's phenomenon in laryngismus 
stridulus, 818 
in status lymphaticus, 730 
in tetany, 811 

in tuberculous meningitis, 435 
roseola, 291. See Eotheln 
Tube, nursing, 188 

Tubercle bacillus, scrofulosis and, 412 
Tuberculin tests, 424, 429 

in tuberculous meningitis, 442 
Tuoerculosis, 417 
of bones, 755 

of skull, 756 
of brain, 443 
in bronchiectasis, 609 
congenital, 419 

congenitally weak infants and, 184 
contra-indication to maternal nurs- 
ing, 123 
endocarditis and, 690 
enlargement of lymph-nodes in, 715 
fibrinous bronchitis and, 601 
foetal, 419 

bacillary form of, 420 
characteristics of, 420 



Tuberculosis, foetal, etiology of, 419 
placental infection in, 420 
forms of, 418 

aerogenous, 418 
alimentary, 419 
dermogenous, 419 
enterogenous, 419 
hematogenous, 419 
lymphogenous, 419 
frequency of, in childhood, 417 
general, 417 
of heart, 432 
human milk and, 97, 98 
indican in urine in, 33 
from infected cows' milk, 105 
of kidney, 787 
of larynx, 432, 596 
local, 417 

of mesenteric glands, 431 
diagnosis of, 431 
pathogenesis of, 431 
prognosis of, 432 
symptoms of, 431 
treatment of, 432 
pathogenesis of, 418 
pericarditis and, 674 
of pericardium, 432 
of peritoneum, 426 
acute, 426 
adhesive, 427 
chronic, 426 
course of, 430 
diagnosis of, 429 

from non-tuberculous peri- 
tonitis, 429 
from pneumococcal peri- 
tonitis, 572 
etiology of, 428 
laparotomy in, 430 
miliary, 427 
nodular, 427 
occurrence of, 426 
pathology of, 427 
physical signs of, 428 
symptoms of, 427 
treatment of, 430 
tuberculin test in, 429 
pertussis convulsiva and, 376 
of pleura, 432 
portals of entry of, 418 
pulmonary, 421 

bronchopneumonia and, 422 
diagnosis of, 424 
haemoptysis in, 423 
localization of, 422 
sputum in, 423 
symptoms of, 422 
temperature in, 423 
trauma and, 423 
treatment of, 426 
tuberculin test for, 424 

allergistic reaction in, 

426 
Calmette's, 424. 425 
conjunctival, 425 



INDEX. 



941 



Tuberculosis, pulmonary, tuberculin test 
- for, cutaneous scari- 
fication, 425 
methods of, 425 
Moro's inunction, 424 
subcutaneous, 425 
von Pirquet 's, 424, 

425 
Wolf-Eissner's, 424, 
425 
scarlet fever and, 280 
spread of, modes of, 418 
of thymus gland, 729 
Tuberculous empyema, 666 

inflammation, diagnosis of, from 
acute infectious osteomyelitis, 
758 
meningitis, 432 
pericarditis, 675 
peritonitis, 426 
acute, 569 
Tubular nephritis, 776 
Tumefaction in mastoid disease, 767 
Tumors, adenoid, of umbilicus, 207 
of brain, 840 

cerebral, ataxic gait in, 50 
contour of abdomen in, 44 
in intussusception, 544 
of larynx, 596 
of liver, 567 
phantom, of liver, 562 
polypoid, of umbilicus, 207 
Twitchings, muscular, in chorea, 825 
Tympanic membrane in otitis, 760 

resonance, normal, 613 
Tympanites, 45, 509 

in appendicitis, 509 
in acute appendicitis, 550 
in bronchopneumonia, 637 
colic and, 508 
liver dulness in, 44 
in gastro-enteritis, 45 
in lobar pneumonia, 631 
in peritonitis, 44, 509 
in pneumonia, 45, 509 
in rachitis, 45 
treatment of, 509 
Tympanum, appearance of, in otitis, 764 
Typhoid fever, 318 

abscess in, subcutaneous, 327 
amblyopia in, 328 
aphasia in, 328 
arthritis in, 328 
ataxia in, 328 
blood in, 327 
blood-cultures in, 331 
brand bath in, 65, 333 
bronchitis in, 328 
bronchopneumonia and, 326, 

639 
cholecystitis in, 326 
complications of, 327 
diagnosis of, 330 

from acute peritonitis, 570 
from appendicitis, 330, 332 
acute, 551 



Typhoid fever, diagnosis of, from enter- 
itis, 330 
from cerebrospinal menin- 
gitis, 358 
from lobar penumonia, 629 
from meningitis, 330 
from pneumonia, 330 
diet in, 333 
diphtheria in, 328 
duration of, 330 
Ehrlich diazo reaction in, 331 
endocarditis and, 690 
enema in, 73 
foetal, 319 
full bath in, 65 
gangrene of lung in, 328 
gavage in, 71 
headache in, 320 
heart in, 326 
hemorrhages in, 325 
human milk and, 97, 98 
hydrotherapy in, 333 
infantile, 319 

intestinal perforation in, 328 
diagnosis of, 333 
prognosis of, 330 
symptoms of, 329 
treatment of, 334 
Kernig's symptom in, 50 
kidneys in, 328 
lungs in, 326, 328 
mastoid disease and, 766 
mastoiditis in, 326 
melancholia in, 328 
mumps and, 372 
nephritis in, 328 
nervous symptoms in, 326 
occurrence of, 318 
onset of, 320 
onychia in, 327 
otitis in, 326 
pain in, 325 
paralysis in, 328 
parotitis in, 326 
pathology of, 320 
pneumonia in, 326, 328 
pregnancy and, 319 
prognosis of, 332 
ptosis in, 32S 
pyuria in, 328 
relapses in, 327 
roseola in, 322 

diagnosis of, from mea- 
sles, 307 
sequela 1 of, 327 
skin in, 327 
spleen in, 323 
symptoms of, 320 
temperature in, 324 
tongue in. 326 
treatment of, 332 
vomiting in. 326 
WidaJ reaction in. 321. 331 
Typhus, abdominal, 318 



942 



INDEX. 



Ulcer of stomach, oil 

of umbilicus, 208 
Ulcerative endocarditis, 695 

stomatitis, 480 
Ulceromembranous tonsillitis, 591 
Umbilical arteries, closure of, 167 
cord, 52 

dressing of, 52 
fungus of, 53 
gangrene of, 53 
ligation of, faulty, omphalor- 
rhagia in, 211 
in premature infants, 52 
stump of, 52 

drying of, 53 
falling off of, 52 
tying of, 52 
hernia, 213 
veins, closure of, 168 
vessels, infection of, 209 
Umbilicus, adenoid tumors of, 207 
blennorrhea of, 207 

treatment of, 208 
diseases of, 206 
enteratomata of, 207 
erysipelas of, 209 
fungus of, 207 

treatment of, 207 
gangrene of, 208 

treatment of. 208 
granuloma of, 207 
hemorrhage from, 211 

idiopathic, 212 
hernia of, 213. See Hernia, umbilical 
infection of, 202 
inflammation of, 206 
phlebitis of, 210 
phlegmon of, 208 

treatment of, 208 
in pneumococcal peritonitis, 572 
polypoid tumors of, 207 
seborrhea of, 886 
in sepsis in newborn, 202, 203 
ulcer of, 208 

treatment of, 208 
veins of, inflammation of, 210 
vessels of, infection of, 209 
Uncinaria americana, 558 
Uncinariasis, 558 

anaemia in, progressive, 559 
diagnosis of, 559 
etiology of, 558 
prevalence of, 558 
symptoms of, 559 
treatment of, 559 
Uraemia in scarlet fever, 273, 279 
Urea, excretion of, by infants, 87 
in newborn, 173 
in urine, 32 
Uric acid infarction, 34, 775 
etiology of, 34 
in newborn, 34 
in newborn, 173 
in urine, 34 



Urine, acetone in, 33 

in eclampsia, 33 
in exanthematous fevers. 33 
in pneumonia, 33 
albumin in, 33 
biliary pigment in, 31 
in bottle-fed children, 31, 32 
in breast-fed children, 31, 32 
casts in, 34 
dextrose in, 34 
diacetic acid in, 33 

in exanthematous fevers, 
34 
examination of, 38 
indican in, 33 

in artificially fed children, 33 
in gastro-enteritis, 33 
in suppurative maladies, 33 
in tuberculosis, 33 
in newborn, 172 
odor of, 31 

physical characteristics of, 31 
quantity of, 31, 32 
in sepsis in newborn, 204 
specific gravity of, 31 
staining of, 38 
urea in, 32 
uric acid in, 34 
urobilin in, 34 
Urobilin in urine, 34 
Urogenital blennorrhea, 790 
infections, 202 
tract, diseases of, 790 
Uvula, bifid, 488 

malformation of, 488 



Vaccination, 314 

age and, 315 

complications of, 316 

contra-indications for, 315 

course of, 316 

eczema in, 317 

eruptions in, 317 

fever in, 316 

infection and, 317 

lymph for, animal. 315 
humanized. 315 

management of, 318 

method of, 315 

re-vaccination, 318 

suppuration of joints due to, 317 

tetanus and, 317 

vaccinia in, generalized, 317 

vesicles of, 316 
Vaccinia, 314 

generalized, in vaccination. 317 
Vagina in sepsis in newborn, 203 
Valentine's beef -juice, 115 
Valvular anomalies in congenital dis- 
ease of heart, 687 

disease of heart, chronic, 699 
Vapor spray, 68 

in acute laryngitis, 68 
Varicella, 310 



INDEX. 



943 



Varicella, bronchopneumonia and, 639 
complications of, 312 
diagnosis of, 313 
exanthema in, 311 
gangrenosa, 312 
immunity to, 310 
incubation of, 310 
joints in, 313 
mumps and, 372 
nephritis in, 312 
nervous system in, 313 
otitis in, 313 
pneumonia in, 313 
prognosis of, 314 
symptoms of, 310 
treatment of, 314 
Vegetations, adenoid, 579 
Vejos, 118 
Venous hum, 706 

Ventricles, dilatation of, in septic endo- 
carditis, 696 
hypertrophy of, in congenital dis- 
ease of heart, 686 
Ventricular septum, congenital defects 
of, 689 
cyanosis in, 690 
murmurs in, 690 
Vermiform appendix, 547 
Vernix caseosa, 53, 170 
Vertigo in tumor of brain, 841 
Vesicular eczema, 885 

emphysema of lungs, 602 
Vincent's bacillus in ulceromembranous 

tonsillitis, 592 
Vision, defective, position of head in, 40 
Vomiting in abscess of brain, 508 

in acute gastro-enteric infection, 
520, 524 
peritonitis, 569 
after eating, 507 
in appendicitis, 507 
in artificial infant-feeding, 154 
cyclic, 503 

acetone breath in, 505 
constipation in, 504 
diagnosis of, 505 
etiology of, 503 
prognosis of, 505 
symptoms of, 504 
urine in, 505 
treatment of, 505 
in dilatation of stomach, 510 
habitual, of infants, 503 
in infectious diseases, 507 
in intestinal obstruction, 507 
in intussusception, 543 
in meningitis, 508 
in mixed infant-feeding, 132 
in onset of illness, 37 
overflow, in mixed infant-feeding, 

132 
periodic, 503 

in pyloric stenosis, 507, 513 
recurrent, 503 
stomach washing in. 69 
in tumor of brain. 5fK. S41 



Vomiting, uncontrollable, 74 

Von Jaksch's disease, 739 

Von Pirquet's tuberculin test, 424, 425 

Vulvovaginitis, 790 

arthritis and, 792 

complications of, 791 

conjunctivitis and, 792 
Vulva, diphtheria of, 392 

etiology of, 790 

gonococci in, 791 

occurrence of, 790 

peritonitis and, 791 

prophylaxis of, 792 

symptoms, 791 

treatment of, 792 

W 

Walking, development of, 35 
Wandering rash of tongue, 486 
Water, administration of, in gastro- 
enteritis, 83 

in cows' milk, 102 

excretion of, "by infants, 88 
in human milk, 82 

percentage of, 82 

role of, in nutrition, 82 
Weaning, 160, 161 

artificial infant foods, at time of, 

121, 122 
difficulties in, j.o0 
time of, 160 

Weight, average, 24 25 
chart of, 24 
increase of, 25 

in bottle-fed 'children, 25, 150 
in breast-fed children, 25 
daily, 25, 26 
loss of, following birth, 24 
Werlhof 's disease, 749 
Wet-nurse, age of, 125 
breast of, 125 
examination of, 125 

baby of, 125 
milk of, nail-test for, 126 
quality of, 126 
quantity of, 126 
nipples of, 125 
selection of, 125 
Wet-nursing, objections to, 122, 123 
transmission of diathesis through, 

122, 123 

Whey, in artificial infant-feeding, 156 
composition of, 155 
laboratory combinations, table of. 

157 
preparation of. 155. 156 
proteids in human milk. 91. 92 
White blood-cells. 735 
Whooping-cough, 372 
Widal reaction in typhoid fever, 321, 

331 
Winckel's disease. 222 

diagnosis of. 223 
' from acuta fatty degen- 
eration of newbon 



944 IN BEX. 

Winckel's disease, diagnosis of, from Worm, hook-, 558 
Buhl's disease, 223 intestinal, 555 

etiology of, 223 pin-, 557 

hemorrhages in, 219, 223 round, 556 

pathology of, 223 tape-, 557 

prognosis of, 223 thread-, 557 

in sepsis in newborn, 201 Wound infection with scarlet fever, 270 

symptoms of, 223 Wrist-drop in chorea, 825 
treatment of, 223 i n multiple neuritis, 855 

Woodward's method of estimation of Wyeth's beef -juice, 115 
proteids, 102 
milk burette, 102 Y 

Wool, clothing, 61 

Wolf-Eissner 's tuberculin test, 424, 425 Yellow atrophy of liver, acute, 567 






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One copy del. to Cat. Div. 









